j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 7 ( 2 0 1 5 ) 2 4 0 e2 4 6

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.JournalofSurgicalResearch.com

Association for Academic Surgery

Prehospital care and transportation of pediatric

trauma patients

Casey J. Allen, MD, Laura F. Teisch, BS, Jonathan P. Meizoso, MD,

Juliet J. Ray, MD, Carl I. Schulman, MD, PhD, Nicholas Namias, MD,
Juan E. Sola, MD, and Kenneth G. Proctor, PhD*
Division of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery,
University of Miami Miller School of Medicine, Miami, Florida

article info abstract

Article history: Background: Despite advances in prehospital emergency medical services (EMS), most
Received 15 December 2014 advocate scoop-and-run over stay-and-play. However, there are almost no studies in
Received in revised form children. We hypothesize that the transportation of mortally injured children is delayed
29 January 2015 and that the performance of prehospital interventions (PHIs) themselves delay trans-
Accepted 4 March 2015 portation and worsen outcomes in pediatric trauma patients.
Available online 10 March 2015 Materials and methods: A total of 1884 admissions (
17-y-old) transported via EMS to a level
1 trauma center from January 2000eDecember 2012 were reviewed. Propensity scores were
Keywords: assigned based on the need for a PHI (intubation and resuscitation). PHI and non-PHI
Emergency medical services cohorts were matched 1:1 to compare outcomes. Data are expressed as mean  standard
Children deviation or median (interquartile range).
Adolescents Results: The population was 11  6 y, 70% male, 50% black, 76% blunt injury, injury severity
Ambulance score 13  12, length of stay 3 (7) d, and mortality 3.6%. Incident to EMS arrival was 38 (20)
min, EMS on-scene time was 14 (12) min, and overall time of arrival to hospital was 27 (15)
min. Patients that were mortally wounded, despite having significantly higher rates of PHI,
still had similar transportation times to those who survived. Mostly every measure of
injury severity was worse in those who required PHI. When these factors were corrected,
EMS on-scene time was 18 (13) versus 14 (13) min (P 0.551), EMS arrival at the hospital was
31 (16) versus 28 (12) min (P 0.292), length of stay was 5 (15) versus 4 (12) d (P 0.368), and
mortality was 31.7% versus 28.3% (P 0.842) for PHI and non-PHI matched cohorts.
Conclusions: PHIs did not delay transportation times or worsen outcomes in pediatric
trauma patients. Although mortally injured children more often required PHIs, this did not
delay transportation to the trauma center.
2015 Elsevier Inc. All rights reserved.

Portions of these data were presented at the 10th Annual Academic Surgical Congress, Las Vegas, Nevada, February 2e4, 2015.
* Corresponding author. Divisions of Trauma and Surgical Critical Care, Dewitt-Daughtry Family Department of Surgery, University of
Miami Miller School of Medicine, Ryder Trauma Center, 1800 NW 10th Ave, Miami, FL 33136. Tel.: 1 305 585 1178; fax: 1 305 326 7065.
E-mail address: kproctor@miami.edu (K.G. Proctor).
0022-4804/$ e see front matter 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jss.2015.03.005
 j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 7 ( 2 0 1 5 ) 2 4 0 e2 4 6 241

1. Background
In the United States, trauma is the leading cause of morbidity
and mortality among the pediatric population. Over 9 million
children annually visit an emergency department because of
an unintentional injury with over 12,000 deaths [1].
Aggressive efforts to improve emergency transportation of
injured children to major trauma centers [2e4] save over
2,000 lives annually [5]. Regionalization of trauma care and
implementation of helicopter emergency medical services
(EMS) have also improved outcomes [6,7]. Furthermore, EMS
often provides advanced care at the scene of trauma, which
should theoretically improve outcome. However, most cur-
rent data do not support this practice, at least in the adult
population. Indeed, although some prehospital interventions
(PHIs) can be lifesaving, those beyond basic life support are
generally ineffective. In a surprising number of cases, PHI
may be futile, unnecessary, or even harmful [8,9]. Thus, in an
urban environment with short transport times to trauma
centers, outcomes mostly depend on the mechanism and
severity of injury and the distance from the trauma center,
rather than PHI performed by skilled EMS [10]. Regardless, in
many trauma systems the policy is scoop-and-run not
stay-and-play [8,9]. However, this idea has never been
rigorously examined in the pediatric population. We hy-
pothesize that the transportation of mortally injured children
is delayed and that the performance of PHIs themselves delay
transportation and worsen outcomes in pediatric trauma
patients.
[GCS], injury severity score [ISS], traumatic brain injury [TBI],
and subsequent blood transfusion requirement or operative
intervention on arrival). A 1:1 fixed ratio nearest-neighbor
matching was performed to compare transportation times
and outcomes of the PHI and non-PHI cohorts to minimize
bias without sacrificing power [12]. Also, each independent
PHI was separately assigned a propensity score, matched and
compared as aforementioned.
Statistical analyses were performed using SPSS version 21
(IBM Corporation, Armonk, NY). Parametric data are reported
as mean  standard deviation, and nonparametric data are
reported as median (interquartile range). Continuous data
were compared using a t-test or ManneWhitney U-test, as
appropriate. Categorical variables were compared using a chi-
square or Fisher exact test, as appropriate. For comparison of
propensity-matched cohorts, Wilcoxon signed-rank tests for
continuous variables and McNemar chi-square test for cate-
gorical variables were performed [13]. Statistical significance
was determined at alpha level 0.05.
3. Results
Table 1 shows that 1884 pediatric trauma patients were
transported via EMS to this trauma center over the study
period. Characteristics included age 11  6 y, 70% male, 50%
Table 1 e Patient demographics (n [ 1884).
Characteristics

2. Materials and methods Age, y 11  6

Sex, %
Male 69.5
After approval from the University of Miami Miller School of
Female 30.5
Medicine Institutional Review Board, consecutive pediatric Race, %
admissions (
17 -y-old) from January 2000eDecember 2012 at Black 49.6
the Ryder Trauma Center in Miami, Florida, were retrospec- Hispanic 27.2
tively reviewed. Those pregnant, incarcerated, or not White 22.9
admitted to either the trauma or pediatric surgery services Other 0.3
Mechanism of injury, %
were excluded from analysis. Demographics, mechanisms of
Blunt 76.3
injury, mode of transportation, EMS transportation times,
Penetrating 23.7
PHIs, injuries sustained, length of stay (LOS), and survival Transportation modality, %
were reviewed. Hypotension and tachycardia were defined as Ground 60.1
any value outside of the normal age-specific range. Air 39.9
On-scene shock was defined by EMS, based on hemody- Incident to EMS arrival time, min 38 (20)
namics (systolic blood pressure, heart rate, and altered mental EMS time spent at scene, min 14 (12)
Time from scene arrival to hospital arrival, min 27 (15)
status, etc.) and/or signs of external blood loss [11]. In south
Scene shock, % 5.9
Florida, children with on-scene shock are considered to be
Scene CPR, % 1.8
hypovolemic from hemorrhage; the EMS protocol is to gain GCS 15 (1)
intravenous (IV) or intraosseous access for fluid resuscitation Hypotension, % 6.0
and/or place an extremity tourniquet for hemorrhage control Tachycardia, % 31.9
[11]. Therefore, in south Florida, on-scene shock is synony- BE, mEq/L 35
mous with prehospital IV fluid resuscitation and/or extremity Hematocrit, % 37  6
TBI, % 4.4
tourniquet placement for hemorrhage control. Accordingly,
ISS 13  12
PHI was defined as either endotracheal tube intubation, car- LOS, d 3 (7)
diopulmonary resuscitation (CPR), and/or on-scene shock. Mortality, % 3.6
Propensity scores were based on a logistic regression
Data are expressed as mean  standard deviation or median
model for predicting the need to undergo a PHI using patient
(interquartile range).
and injury characteristics (i.e., age, scene Glasgow Coma Scale
242 j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 7 ( 2 0 1 5 ) 2 4 0 e2 4 6

Table 2 e Ground versus air transportation (n [ 1884).

Characteristics Ground (n 1132) Air (n 752)

Survivors Nonsurvivors P value Survivors Nonsurvivors P value

Age 10  5 12  6 0.080 12  5 14  5 0.028

Mechanism of injury, %
Blunt 73.5 48.5 0.003 81.8 76.5 0.495
Penetrating 26.5 51.5 18.2 23.5
Incident to arrival time, min 33 (17) 27 (10) 0.006 46 (17) 47 (13) 0.601
EMS time spent at scene, min 13 (9) 8 (4) 0.004 16 (14) 22 (13) 0.059
Time from scene arrival to hospital arrival, min 24 (12) 22 (16) 0.066 31 (18) 33 (16) 0.194
Scene CPR, % 0.3 57.1 <0.001 0.0 18.2 <0.001
Scene intubation, % 0.9 18.2 <0.001 0.9 14.7 <0.001
Scene shock, % 3.8 42.9 <0.001 6.3 40.0 <0.001
GCS 15 (1) 3 (5) <0.001 15 (1) 3 (7) <0.001
BE, mEq/L 2  4 14  12 <0.001 2  3 9  7 <0.001
Hematocrit, % 37  5 28  8 <0.001 38  5 33  7 <0.001
ISS 11  11 38  9 <0.001 13  11 42  16 <0.001
Transfusion, % 8.3 63.6 <0.001 10.2 58.8 <0.001
OR, % 20.2 60.6 <0.001 21.2 73.5 <0.001

Data are expressed as mean  standard deviation or median (interquartile range).

Bold indicates P < 0.05.

black, 76% blunt force injury, GCS 15 (1), initial base excess (BE)
3  5 mEq/L, initial hematocrit 37  6%, ISS 13  12, 4.4% TBI,
LOS 3 (7) d and mortality of 3.6%. Incident to EMS arrival-to-
scene time was 38 (20) min, EMS time-at-scene was 14 (12)
min, and overall time from EMS arrival at the scene to patient
arrival at the hospital was 27 (15) min. Sixty percent arrived
via ground transportation.
Table 2 compares patient demographics, hemodynamics,
and injury severity by mode of transportation in survivors
versus nonsurvivors. In those arriving via ground trans-
portation, nonsurvivors compared with survivors were age
12  6 y versus 10  5 y (P 0.080), incident to EMS arrival time
at the scene was 27 (10) versus 33 (17) min (P 0.006), time spent
at the scene 8 (4) versus 13 (9) min (P 0.004), and EMS arrival at
the scene to patient arrival at the hospital was 22 (16) versus
24 (12) min (P 0.066). Rates of PHI included scene CPR (57.1%
versus 0.3%, P < 0.001), scene intubation (18.2% versus 0.0%,
P < 0.001), and on-scene shock (42.9% versus 3.8%, P < 0.001).
Clinical presentation at the hospital included GCS (3 [5] versus
15 [1], P < 0.001), BE (14  12 versus 2  14 mEq/L, P < 0.001),
hematocrit (28  8% versus 37  5%, P < 0.001), ISS (38  9 versus
11  11, P < 0.001), need for transfusion (63.6% versus 8.3%,
P < 0.001), and need for surgery (60.6% versus 20.2%, P < 0.001).
In those arriving via air transportation, nonsurvivors
compared with survivors were age 14  5 y versus 12  5 y
(P 0.028), incident to EMS arrival time at the scene (46 [17]
versus 47 [13] min, P 0.601), time spent at the scene (22 [13]
versus 16 [14] min, P 0.059), and time from EMS arrival at the
scene to patient arrival at the hospital (33 [16] versus 31 [18]
min, P 0.194). Rates of PHI were scene CPR (18.2% versus 0.0%,
P < 0.001), scene intubation (14.7% versus 0.9%, P < 0.001), and
on-scene shock (40.0% versus 6.3%, P < 0.001). Clinical pre-
sentation at the hospital included GCS (3 [7] versus 15 [1],
P < 0.001), BE (9  7 versus 2  3 mEq/L, P < 0.001), hemat-
ocrit (33  7% versus 38  5%, P < 0.001), ISS (42  16 versus
13  11, P < 0.001), need for transfusion (58.8% versus 10.2%,
P < 0.001), and need for surgery (73.5% versus 21.2%, P < 0.001).
Table 3 compares the demographics, transportation mo-
dality, and clinical presentation between those who received
PHI and those who did not. Age was different (13  5 y versus
11  6 y, P < 0.001) but gender (76.2% male versus 69.1% male,
P 0.097) and mode of transportation (53.3% ground versus
60.6% ground, P 0.112) were not. Incident to EMS arrival time
to the scene (43 [14] versus 38 [20] min, P 0.206), time at the
scene (14 [12] versus 14 [12] min, P 0.949), and time from
scene arrival to patient arrival at the hospital (27 [15] versus
27 [15] min, P 0.574) were similar.
Heart rate (101  49 versus 110  42 beats per min, P 0.248)
was similar, but most other measures were worse in the group
who received PHI, including on-scene systolic blood pressure
(79  24 mm Hg versus 118  22 mm Hg, P < 0.001), GCS (14 [11]
versus 15 [1], P < 0.001), arrival hypotension (29.8% versus 4.3%,
P < 0.001), tachycardia (52.2% versus 30.5%, P 0.002), BE (6 
7 versus 3  4 mEq/L, P < 0.001), hematocrit (33  7% versus
37  5%, P < 0.001), AIS (3.3  1.2 versus 2.3  1.1, P < 0.001), ISS
(23  15 versus 12  12, P < 0.001), TBI (10.7% versus 4.0%,
P 0.001), need for transfusion (36.9% versus 9.1%, P < 0.001),
and need for operation (45.9% versus 20.5%, P < 0.001). Those
with PHI also had a 10 fold higher rate of mortality (23.5%
versus 2.2%, P < 0.001).
When comparing those intubated at the scene to those not
intubated at the scene in regard to transport times included
time from incident to EMS arrival (46 [18] versus 38 [21] min,
P 0.137), EMS time spent at the scene (14 [12] versus 18 [14]
min, P 0.123), and time from EMS arrival at the scene to
patient arrival at the hospital (27 [15] versus 32 [14] min,
P 0.063). Outcomes included LOS (7 [19] versus 3 [7] d,
P 0.045) and mortality (42.3% versus 3.2%, P < 0.001).
In those with on-scene shock compared with those
without shock, incident to EMS arrival was 38 (21) versus
42 (24) min (P 0.449), EMS time spent at the scene was 14
(12) versus 13 (11) min (P 0.518), and time from EMS arrival
at the scene to patient arrival at the hospital was 27 (15)
versus 27 (15) min (P 0.935). Outcomes including LOS were 5
 j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 7 ( 2 0 1 5 ) 2 4 0 e2 4 6 243

Table 3 e Comparison of patients who underwent PHI Table 4 e Comparison of patients who underwent PHI
versus no PHI (n [ 1884). versus no PHI matched for transportation modality and
Characteristics No PHI PHI P propensity to require PHI (n [ 120).
(n 1762) (n 122) value Characteristics No PHI PHI P
(n 60) (n 60) value
Age 11  6 13  5 <0.001
Sex, % Age 13  5 13  5 0.287
Male 69.1 76.2 0.097 Sex, %
Female 30.9 23.8 Male 68.3 75.0 0.346
Mechanism of injury, % Female 31.7 25.0
Blunt 77.4 60.7 <0.001 Mechanism of injury, %
Penetrating 22.6 39.3 Blunt 80.0 81.7 1.000
Transportation modality, % Penetrating 20.0 18.3
Ground 60.6 53.3 0.112 Incident to arrival time, min 41 (18) 46 (16) 0.350
Air 39.4 46.7 EMS time spent at scene, min 14 (13) 18 (13) 0.667
Incident to arrival 38 (20) 43 (14) 0.206 Time from scene arrival to 28 (12) 31 (16) 0.751
time, min hospital arrival, min
EMS time spent at 14 (12) 14 (12) 0.949 Scene SBP 109  22 79  27 <0.001
scene, min GCS 7 (11) 7 (12) 0.225
Time from scene arrival to 27 (15) 27 (15) 0.574 Hypotension, % 31.7 25.4 0.700
hospital arrival, min Tachycardia, % 50.0 65.0 1.000
Scene pulse 110  42 101  49 0.248 BE, mEq/L 7  8 6  7 0.907
Scene SBP 118  22 79  24 <0.001 Hematocrit, % 35  7 34  6 0.975
Altered mental status, % 30.9% 56.6% <0.001 TBI 15.0% 20.0% 0.648
GCS 15 (1) 14 (11) <0.001 AIS head 31 31 0.279
Hypotension, % 4.3 29.8 <0.001 ISS 28  18 30  14 0.315
Tachycardia, % 30.5 52.2 0.002 Transfusion, % 40.0 40.0 1.000
BE, mEq/L 3  4 6  7 <0.001 OR, % 41.7 40.0 1.000
Hematocrit, % 37  5 33  7 <0.001 LOS, d 4 (12) 5 (15) 0.343
TBI, % 4.0 10.7 0.001 Mortality, % 28.3 31.7 0.824
AIS head 2.3  1.1 3.3  1.2 <0.001
AIS abbreviated injury score; SBP systolic blood pressure.
ISS 12  12 23  15 <0.001
Data are expressed as mean  standard deviation or median
Transfusion, % 9.1 36.9 <0.001
(interquartile range).
OR, % 20.5 45.9 <0.001
Bold indicates P < 0.05.
Mortality, % 2.2 23.5 <0.001

AIS abbreviated injury score; SBP systolic blood pressure.

Data are expressed as mean  standard deviation or median
(interquartile range).
Bold indicates P < 0.05. 4. Discussion

(10) versus 3 (6) d (P 0.005), and mortality was 19.8% versus
1.7% (P < 0.001).
Table 4 compares a matched subset of children based on
transportation modality and propensity to require a PHI (using
age, scene GCS, ISS, TBI, and subsequent blood transfusion
requirement or operative intervention on arrival). Sixty pa-
tients were compared in each cohort. Incident to EMS arrival
time at the scene (46 [16] versus 41 [18] min, P 0.350), time
spent at the scene (18 [13] versus 14 [13] min, P 0.667), and
time from EMS arrival at the scene to patient arrival at the
hospital (31 [16] versus 28 [12] min, P 0.751) were the same. In
propensity-matched PHI versus non-PHI cohorts on hospital
arrival, characteristics included hypotension (25.4% versus
31.7%, P 0.700), tachycardia (65.0% versus 50.0%, P 1.000), BE
(6  7 versus 7  8 mEq/L, P 0.907), hematocrit (34  6%
versus 35  7%, P 0.975). Outcomes included LOS (5 [15] versus
4 [12] d, P 0.343) and mortality (31.7% versus 28.3%, P 0.824).
Finally, independent PHI was separately assigned a pro-
pensity score, matched and compared. Total transportation
times between matched cohorts were similar with CPR (24 [6]
versus 22 [8] min), intubation (32 [14] versus 30 [12] min) and on-
scene shock (27 [15] versus 27 [15] min); all P not significant.
The main finding of the present study is that PHIs did not
delay transportation times or worsen outcomes in pediatric
trauma patients. Although mortally injured children more
often required PHIs, this did not delay transportation to the
trauma center. These results confirm and extend our recent
study evaluating PHI in adult trauma patients [14] but, to our
knowledge, this is among the first studies evaluating scoop-
and-run versus stay-and-play in pediatric trauma patients.
Florida has been a leader in the development of trauma
systems since the early 1980s. Through cooperative efforts,
Florida has enacted comprehensive legislation, provided sub-
stantial funding, and established a network of trauma centers
and highly skilled EMS that altogether provide coverage for
most of the population [15]. While prehospital time may take
up a large fraction of the golden hour of trauma care [7], our
findings support the concept that PHI by skilled EMS do not
delay time to definitive care of critically injured pediatric
trauma patients at least in south Florida. Svenson et al. [16]
showed that in pediatric prehospital care, advanced life sup-
port procedures did not prolong scene times even in the rural
setting, but Cudnik et al. [17] showed that prehospital intuba-
tion increases out-of-hospital time. Sampalis et al. [18] showed
that prehospital time over 60 min increased mortality rates; but
244 j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 7 ( 2 0 1 5 ) 2 4 0 e2 4 6
in our system, the time from EMS arrival at the scene to arrival
at the trauma center was well within this window.
In 1994, Zaritsky et al. [19] showed that most prehospital
networks were deficient in pediatric care. In the past two
decades, there have been many improvements [6]. In chil-
dren who sustain TBI, helicopter EMS increases survival by
reducing transport time to trauma centers [6]. Regionalization
of trauma care, as recommended by the Institute of Medicine,
is now the nationwide standard for pediatric trauma [20]. Field
triage decisions by experienced EMS are now consistent with
the pediatric assessment triangle [21,22].
Pediatric emergency patients have unique needs,
requiring specialized personnel, training, equipment, sup-
plies, and medications. Deficiencies in these areas have
resulted in historically poorer outcomes for pediatric patients
versus adults [23]. The Health Resources and Services
Administration now requires that all EMS for children
grantees report on specific performance measures. This in-
cludes implementation of a standardized system recognizing
hospitals that are able to stabilize or manage pediatric
medical emergencies and trauma cases [23]. Prehospital
triage, assigning the most severely injured to trauma centers
and the less severely injured to nearby hospitals, is essential
for this practice [7].
We recently reviewed 3733 consecutive adult trauma acti-
vations in south Florida and reported that PHI performed by
skilled EMS reduced mortality by half without delaying
transport in those at highest risk for death [14]. Nevertheless,
there remains major controversy regarding the benefits of
PHIs on transport time and patient outcomes in other trauma
systems. A recent clinical trial showed that out-of-hospital
pediatric intubation did not improve survival or neurologic
outcome in comparison with bag valve mask ventilation in an
urban EMS system [24]. In this present study, the mortality
was higher in the intubated-on-scene cohort, which could be
attributed to the PHI itself or to the severity of the injury. For
this reason, a more sophisticated analysis was required.
When controlling for injury severity, PHIs did not worsen LOS
or survival in pediatric trauma patients. This agrees with
earlier work showing that pediatric patients arriving to
emergency departments via EMS have higher acuity illness
than those arriving by other means [25]. Some PHI might be
futile, and others might be unnecessary, but it is reasonable to
expect that those who required PHI were inherently at a
higher risk for adverse outcomes.
For EMS providers, the challenge in pediatric patients is to
recognize shock early because children present differently
than adults with shock. Adults become hypotensive quickly
with 10%e15% blood loss, whereas children compensate with
tachycardia and peripheral vasoconstriction. Hypotension
does not develop until 25%e30% blood loss [26]. Although vital
signs may not be as predictive of hemorrhage as other in-
dicators of shock, when vitals are lost, children are often
unsalveagable [27,28]. Once diagnosed with shock, these pa-
tients should receive IV fluids, inotrope therapy, and proper
airway management as long as transport is not delayed [29].
Carcillo et al. found that the rapid resuscitation via the Pedi-
atric Advanced Life Support guidelines for pediatric shock
decreased mortality four-fold. Each hour without resuscita-
tion increased mortality by 40%, further indicating the
importance of EMS to properly rapidly identify and treat
children in shock [30].
Table 3 shows that virtually every index of injury severity
was worse in those who received PHI, but there was no dif-
ference in the scene or transport time. After matching cohorts
for the propensity to undergo PHI (i.e., need for surgery and/or
transfusion, ISS, and altered mental status, etc.), there was
still no difference in transportation times, LOS, or mortality
between the two groups. Also, despite having an indication for
PHI, both groups were of similar hemodynamic status on
arrival to the hospital, which may be attributable to the ben-
efits of PHI by skilled EMS. The National Association of State
EMS officials created a State EMS System model to help
regional EMS networks self-assess their systems and evaluate
their maturity [31]. There are a variety of categorical com-
ponents of this evaluation as follows: (1) system leadership,
organization, regulation and policy subsystem; (2) financial
resource management; (3) human resource management; (4)
transport resource management; (5) facility and specialty care
regionalization; (6) public access and communications sub-
system; (7) public information, education and prevention
subsystem; (8) clinical care, integration of care, and medical
direction; (9) information, evaluation and research subsystem;
and (10) large-scale emergency preparedness and response
subsystem [31]. The mature nature of the prehospital system
in south Florida allows more medics per each EMS unit dis-
charged to the scene of an incident and more available units
for our level 1 trauma center. Our urban level 1 trauma center
is a part of an EMS network with specialty care regionalization
where patients are triaged and transported to the needed level
of care facility. Thus, these findings might only be achievable
in a mature EMS system with increased manpower and
transportation availabilities.
There are limitations to this study. These data were
collected retrospectively and at a single institution. Some
variables may have been missing or misclassified. The cut-off
age was arbitrarily set at 17 y even though most recognize that
injuries in mature teenagers are not the same as those in
young children. Some reports set the age for pediatric as
<18 y, whereas others set their cut-off at age 15 or 16. Clearly,
this is not uniform throughout the United States, and it is
beyond the scope of this study to reconcile this issue. The use
of on-scene shock as a surrogate for PHI is debatable. There is
no verification that every on-scene shock patient received
aggressive resuscitation and hemorrhage control but this is
the EMS protocol in this system [11]. In fact, our EMS providers
defined on-scene shock for the trauma registry, and, in
accordance with their standards, a specific measure for which
they would be required to perform potentially lifesaving PHIs.
Still, many of the patients with on-scene shock also under-
went scene intubation and/or CPR; thus, our cohort of those
with PHI is likely adequately representative of a patient cohort
that is severely injured and received more extensive pre-
hospital care. The propensity score match methodology for
statistical analysis is not without limitations. Our study
evaluates a unique population (severely injured pediatric
trauma requiring PHI); and even in our high volume trauma
center, the sample size is limited. Using our statistical meth-
odology, we matched 60 patients with PHI to 60 without.
Because we performed a 1:1 nearest-neighbor match and
 j o u r n a l o f s u r g i c a l r e s e a r c h 1 9 7 ( 2 0 1 5 ) 2 4 0 e2 4 6
because those with PHI were more critically injured, often
there were no near-neighbors in the non-PHI cohort. For this
reason, we had to exclude some PHI patients. Using this 1:1
nearest-neighbor matching further decreased the sample size
for analysis, thus susceptible to possible type 2 error. A power
analysis showed a sample size of 120 patients in each group
would have been required to demonstrate a statistically sig-
nificant difference in transportation times of the propensity-
matched cohorts if similar differences were found with an
extended analysis. Still, a difference of 3 min in total trans-
portation time between PHI and non-PHI cohorts would
arguably be, although statistically significant, not clinically
significant as total transportation time was typically around
30 min. For mortality, between 900 and 1000 patients in each
cohort would be required to show a statistical difference if the
trends continue. This analysis only includes those patients
transported to the trauma center by EMS and subsequently
admitted; thus, these patients likely had a higher injury
severity than the general pediatric population. Also, our
population has a relatively high-rate of firearm related in-
juries which carries a significant risk of mortality in children
[32]. Those who died en-route would not have been included
in our analysis because they were classified as dead-on-
arrival, and not admitted for care. These patients represent a
population that sustained nonsurvivable injuries and likely
would have expired, regardless of care (prehospital or at the
hospital). PHIs were performed under EMS discretion, and no
formal review was done to determine whether each inter-
vention was indicated. Finally, the arrival times from the
scene to the hospital were approximately 30 min. South
Florida has a mature trauma system with EMS that is fully
integrated with advanced life support services; 95.7% of the
population is within 85 min prehospital time to a trauma
center and most trucks have two skilled providers [33].
Therefore, our findings probably cannot be extrapolated to
trauma systems that may require substantially longer travel
times or have one driver and one skilled provider.
As with many interventions intended to prevent ill health,
the effectiveness of PHI has not been subjected to rigorous
evaluation using randomized controlled trials [34]. Although
no absolute benefit is shown, the purpose of this project was
to assess whether PHIs delay transportation and/or adversely
affect outcomes. Likely because of low sample size of the
propensity-matched cohorts and that those who received PHI
were more critically injured, there are numerous factors that
may contribute to the fact that no mortality benefit was found.
5. Conclusions
Within the context of some limitations, it is reasonable to
conclude that, although mortally injured children more often
required PHIs, these patients did not have delayed trans-
portation to the trauma center. Patients who received PHIs by
skilled EMS did not have longer transportation times yet
attained similar hemodynamic parameters on arrival to the
trauma center, as well as attained similar outcomes, despite
having worse initial hemodynamics on-scene. These findings
give further evidence of the benefit of a mature prehospital
EMS network.
245
Acknowledgment
The authors recognize the nursing and administrative staff at
Ryder Trauma Center for their cooperation and assistance
with the patients and their families. In addition, they thank
the EMS personnel who constantly provide outstanding care
to our community.
Authors contributions: C.J.A. is directly responsible for all
aspects of this study. He participated in the analysis and
interpretation of data and drafting of the article. C.J.A., L.F.T.,
J.P.M., J.J.R., C.I.S., N.N., and J.E.S. participated in the revision
of the article and tables. C.J.A., L.F.T., J.P.M., J.J.R. contributed
to the collection of data. L.F.T., J.P.M., and J.J.R. participated in
the experimental design. C.I.S., N.N., and J.E.S. were medically
responsible for the patients and participated in the review of
the article. K.G.P. had overall responsibility for the study,
including conception and experimental design, analysis and
interpretation of data, drafting and revision of the article and
tables, statistical expertise and evaluation, obtaining funding
for this project, and supervision.
Supported in part by grants #N140610670 from the Office of
Naval Research and #09078015 from U.S. Army Medical
Research and Materiel Command
Disclosure
None of the authors have declared conflicts of interest.
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