J. A.

NavascuØs
J. Matute
J. Soleto
M. A. García Casillas
E. Hernµndez
O. Sµnchez-París
E. Molina
E. De Tomµs
J. Cerdµ
R. Romero
Paediatric Trauma in Spain: J. C. De Agustín
F. Aguilar
A Report from the HUGM Trauma Registry J. Vµzquez
Original Article

Abstract (range 1 ± 214 days). Sequelae of some form were detected in

Objectives: To analyse the characteristics of the infant popula-
tion suffering trauma in our setting. To evaluate the importance
of the different aetiological mechanisms. To study the pre- and
intra-hospital management of these children. To describe the rel-
ative significance of the different lesions. To establish the magni-
36.4 % of the patients over 3 years of age. The total mortality
was 0.5% (n = 13), being 12.8 % in the group of patients with an
I.S.S. ³ 15. Conclusions: Analysis of the data in our Registry has
helped us to define the characteristics of the paediatric trauma
population in our setting, to monitor the management of trauma
in the different care levels and to develop prevention pro-

Downloaded by: University of Pittsburgh. Copyrighted material.

tude of paediatric trauma as a social problem in terms of morbid-
ity and mortality. Material and Methods: From January 1995 to
April 2002, a total of 2633 children admitted to our Centre (Hos-
pital Universitario Gregorio Maraæón) after suffering some type
of injury were included in our Trauma Register. 108 variables
have been analysed, including the identification of the patient,
type, site and mechanism of the accident, pre-hospital care,
transport, complete evaluation on admission, indices of injury
severity, diagnostic tests, lesions, treatments performed and
morbidity and mortality. Results: The accidents were more fre-
30 quent in boys than in girls (68.5 % versus 31.5%). The predomi-
nant age group was the 12 ± 15 year old group (36.8 %). There
was a higher frequency of accidents in the street (37.2 %) than at
home (19.4 %) or at school (13.8 %). The most frequent mecha-
nism was a fall (35.6 %), followed by road traffic accidents
(23.7 %). On admission, 14.7 % of the children had a Paediatric
Trauma Score (P.T.S.) £ 8 (n = 388). 3.8 % were considered severe
multiple trauma patients, presenting an Injury Severity Score
(I.S.S.) ³ 15 (n = 101). 4.2 % of the children required intensive care.
The most frequent lesions were those of the locomotor system
(58.1%) and head injuries (34.9 %). Some type of surgical or or-
thopaedic procedure was performed under general anaesthesia
in 1522 patients (57.8 %). The mean length of stay was 4.4 days
grammes. It has also enabled us to compare the results with
those of other centres in terms of morbidity and mortality with
the aim of identifying and correcting any possible deficiencies
in the care system.
Key words
Paediatric trauma ´ epidemiology ´ registry
RØsumØ
Buts: Analyser les caractØristiques de la population pØdiatrique
se prØsentant avec un traumatisme dans notre environnement.
Evaluer limportance des diffØrents mØcanismes Øtiologiques,
Øtudier le management prØ et intra-hospitalier de ces enfants.
DØcrire les diffØrentes lØsions. Etablir limportance du trauma-
tisme pØdiatrique comme un probl›me de sociØtØ en termes de
morbiditØ et de mortalitØ. MatØriel et MØthodes: De Janvier
1995 à Avril 2002, un total de 2 633 enfants ont ØtØ admis dans
notre centre (Hôpital Universitaire Gregorio Maraæon) ayant prØ-
sentØ une blessure incluse dans notre registre des traumatismes.
108 variables ont ØtØ analysØes incluant lidentification du pa-
tient, le type, la localisation et le mØcanisme de laccident, les

Affiliation
Division of Paediatric Surgery, Hospital Infantil ªGregorio Maraæonº, Madrid, Spain

Presented at the 5th European Congress of Paediatric Surgery ± Tours, May 21 ± 25, 2003

Correspondence
Dr. J. A. NavascuØs del Río ´ Servicio de Cirugía Pediµtrica ´ H.G.U. Gregorio Maraæón ´ c/Doctor Castelo, 49 ´
28009 Madrid ´ Spain ´ E-mail: juannavascues@terra.es

Received: January 15, 2004 ´ Accepted after Revision: March 18, 2004

Bibliography
Eur J Pediatr Surg 2005; 15: 30 ± 37 ´  Georg Thieme Verlag KG Stuttgart ´ New York ´
DOI 10.1055/s-2004-821213 ´
ISSN 0939-7248
soins prØ-hospitaliers, le transport, lØvaluation compl›te à lad-
mission, les indices de sØvØritØ, les diagnostics, les lØsions, les
traitements rØalisØs, la morbiditØ, la mortalitØ. RØsultats: Les ac-
cidents sont plus frØquents chez les garcËons que chez les filles
(68,5% contre 31,5%). Lâge prØdominant est le groupe 12/15 ans
(36,8 %). Il y a une grande frØquence daccidents dans la rue
(37,2 %) plus quà la maison (19,4%) ou à lØcole (13,8 %). Le plus
frØquent des mØcanismes est la chute (35,6%) suivi par les acci-
dents de la circulation (23,7 %). A ladmission, 14,7 % des enfants
ont un Paediatric Traumatisme Score (P.T.S.) £ 8 (n = 388). 3,8%
Øtaient comme des patients sØv›res se prØsentant avec un Injury
Severity Score (I.S.S.) ³ 15 (n = 101). 4,2% de ces enfants nØcessi-
taient des soins intensifs. Les plus frØquentes des lØsions Øtaient
celles du syst›me locomoteur (58,1%) et les traumatisme crâ-
niens (34,9 %). Quelques interventions chirurgicales ou orthopØ-
diques Øtaient rØalisØes sous anesthØsie gØnØrale chez 1522 pa-
tients (57,8%). La durØe moyenne de sØjour Øtait de 4,4 jours
(moyenne 1 ± 214 jours). Des sØquelles, de quelque forme que ce
soit, Øtaient dØtectØes chez 36,4 % de ces patients au-delà de 3
ans dâge. La mortalitØ globale Øtait de 0,5 % (n = 13), elle Øtait de
12,8% dans le groupe des patients avec un I.S.S. ³ 15. Conclu-
sions: Lanalyse des ØlØments enregistrØs dans notre registre a
aidØ à dØfinir les caractØristiques des enfants polytraumatisØs, à
amØliorer le management des traumatismes et à dØvelopper un
programme de prØvention. Il nous a ØtØ Øgalement possible de
comparer les rØsultats avec ceux des autres centres en termes
de morbiditØ et de mortalitØ avec le but didentifier et de corriger
les dØfauts de notre syst›me de soins.
Mots-clØs
Traumatisme pØdiatrique ´ ØpidØmiologie ´ registre
Resumen
Objetivo: Analizar las características de la población infantil
afecta por trauma en nuestro medio. Evaluar la importancia del
los mecanismos etiológicos. Estudiar el tratamiento pre e in-
trahospitalario de estos niæos. Describir la significación relativa
de las diferentes lesiones. Establecer la magnitud del trauma pe-
diµtrico como problema social en tØrminos de morbilidad y mor-
talidad. Material y MØtodos: Entre enero de 1995 y abril del
2002 ingresamos en nuestro Centro 2633 niæos que habían sufri-
do alg‚n tipo de traumatismo y que se incluyeron en el registro
de trauma. Analizamos 108 variables que incluyeron la identifi-
cación del paciente, el tipo el lugar y el mecanismo del accidente,
el cuidado preoperatorio, el transporte, la evaluación completa al
ingreso, los índices de gravedad de la lesión, los test diagnósticos
y los tratamientos realizados así como la morbilidad y mortali-
dad. Resultados: Los accidentes fueron mµs frecuentes en niæos
que en niæas (68,5 % vs. 31,5%). La edad predominante fue el gru-
po de 12 a 15 aæos (36,8 %). Hubo mayor frecuencia de accidentes
en la calle (37,2 %) que en casa (19,4 %) o en la escuela (13,8%). El
mecanismo mµs frecuente fue la caída (35,6%) seguido por acci-
dentes de trµfico (23,7%). Al ingreso el 14,7% de los niæos tenían
un score de trauma pediµtrico (PTS) £ 8 (n = 388). 3,8 % fueron
considerados como traumas m‚ltiples graves con un índices de
severidad (ISS) ³ 15 (n = 101). 44,2 % de los niæos requirieron cui-
dados intensivos. Las lesiones mµs frecuentes fueron del sistema
locomotor (58,1%) y traumas craneales (34,9 %). Fue necesario al-
NavascuØs JA et al. Paediatric Trauma in Spain ¼ Eur J Pediatr Surg 2005; 15: 30 ± 37
g‚n tipo de operación quir‚rgica u ortopØdica bajo anestesia ge-
neral en 1522 pacientes (57,8 %). La duración media de estancia
fue de 4,4 días (rango 1 a 214 días). Fueron detectadas secuelas
en 36,4 % de los pacientes de mµs de 3 aæos. La mortalidad global
fue del 0,5% (n = 13) de los que 12,8% eran del grupo con un ISS
³ 15. Conclusiones: El anµlisis de los datos de nuestro registro
ha ayudado a definir las características de la población de trauma
pediµtrico en nuestro medio, a monitorizar el tratamiento del
trauma en diferentes niveles de cuidados y a desarrollar progra-
mas de prevención. TambiØn nos ha permitido comparar los re-
sultados con los de otros centros en tØrminos de morbilidad y
mortalidad con la intención de identificar y corregir las deficien-
cias del sistema sanitario en este aspecto.
Original Article
Palabras clave
Trauma pediµtrico ´ epidemiología ´ registro
Zusammenfassung
Die vorliegende Arbeit versucht, die Charakteristika der trauma-
tischen Versorgung von Patienten in Spanien anlässlich eines
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Traumaregisters (HUGM) zu analysieren. Wichtig ist dabei die
Bedeutung des Unfallmechanismus, die Behandlung am Unfall-
ort und im Krankenhaus, die Bedeutung der verschiedenen Schä-
digungen sowie die Morbidität und Mortalität zu untersuchen.
Krankengut und Methodik: Von Januar 1995 bis April 2002
wurden 2633 Kinder im Hospital Universitario Gregorio Mara-
æón/Spanien nach einem Trauma behandelt und in das Trauma-
register des Krankenhauses aufgenommen. 108 Variable wurden
analysiert. Ergebnisse: Unfälle wurden wesentlich häufiger bei
Knaben als bei Mädchen beobachtet (68,5% gegen 31,5%). Am
häufigsten war das Alter von 12 ± 15 Jahren betroffen (36,8 %), 31
Straûenunfälle (37,2%) waren häufiger als häusliche Unfälle
(19,4%) oder Schulunfälle (13,8%). Der häufigste Unfallmechanis-
mus war ein Sturz (35,6 %) gefolgt von Verkehrsunfällen (23,7%).
Bei der stationären Aufnahme wiesen 14,7% der Kinder einen
pädiatrischen Traumascore (PTS) von £ 8 auf (n = 388). 3,8% der
Kinder zeigten ein schweres Multiorgantrauma mit einem Score
(ISS) von ³ 15 (n = 101). 4,2 % der Patienten mussten auf einer In-
tensivstation behandelt werden. Die häufigsten Verletzungen
betrafen den Bewegungsapparat (58,1%) und den Kopf (34,9%).
Verschiedene chirurgische Eingriffe unter Generalanästhesie wa-
ren bei 1522 Patienten (57,8%) notwendig. Der durchschnittliche
Krankenhausaufenthalt betrug 4,4 Tage (Durchschnitt 1 ± 214
Tage). Folgeerscheinungen wurden bei 36,4 % der Patienten über
3 Jahre beobachtet. Die Mortalität lag bei 0,5 % (n = 13), wobei
die Gruppe der Patienten mit schwerem Trauma (ISS) ³ 15 mit
12,8% daran beteilgt war. Schlussfolgerungen: Die Analyse der
Daten des Tumorzentrums der HUGM zeigte Charakteristika ei-
nes pädiatrischen Traumazentrums auf und ermöglicht eine ge-
zielte Vorbeugung kritischer Punkte. Die Etablierung eines Trau-
maregisters erlaubt darüber hinaus vergleichende Untersuchun-
gen zwischen verschiedenen Zentren, was gerade im Hinblick
auf Morbidität und Mortalität sowie Unfallfaktoren und eventu-
eller Defizite im Versorgungssystem wichtig ist.
Schlüsselwörter
Pädiatrisches Traumazentrum ´ Epidemiologie ´ Traumaregister
 Introduction
500
450
Trauma is the primary cause of mortality in infancy [4, 8,18] and,
400
despite this, there are few epidemiological studies on this sub-

Number of patients
350
ject in our country. Those which do exist are almost always of a Boys
retrospective design and do not consider such important aspects 300
as the adoption of preventive measures, the quality of pre-hospi- 250
tal management or the sequelae, amongst others. In 1995, we in- 200
itiated a Paediatric Trauma Programme in our Centre, with three 150
principal aims: to improve the quality of care of the injured child, 100
Girls
to optimise the training of health personnel in this field and to 50
define the many aspects related to the production of accidents 0
0–1 2–3 4–5 6–7 8–9 10–11 12–13 14–15
in infancy. Achieving this final objective will, in turn, enable us
Years
to introduce preventive measures, adjust the health resources
Original Article

appropriately and monitor the quality of the health care in each Fig. 1 Sex distribution in each of the age groups.
of the care levels. The tool used for this purpose is the Paediatric
Trauma Register, a computerised database which is updated on a
daily basis and which includes all the children admitted to our
600
Centre after suffering some type of injury [6, 9 ± 17].
554
500
The objective of the present paper is to present the results of the
analysis of this Register in order to progress a little further in our 400

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415
understanding of some aspects of Paediatric Trauma. 353
348
300 309
247
200
Material and Methods 202 205

100
Each register was made up of 108 variables which included the
identity of the patient, type, site, and mechanism of the accident, 0
pre-hospital management, transport, complete evaluation on ad- 0–1 2–3 4–5 6–7 8–9 10–11 12–13 14–15
mission, indices of injury severity, diagnostic tests, lesions, treat- Years
ments performed, and morbidity and mortality. The indices of Fig. 2 Relative frequency of each sex in each of the aetiological
32 severity we used were the Glasgow Coma Scale [20], the Paediat- mechanisms.
ric Trauma Score [21] and the Injury Severity Score [3]. The eval-
uation of the sequelae was based on the Injury Impairment Scale
[23], though only in children over 3 years of age due to the diffi- There was a higher frequency of accidents in the street (37.2 %)
culty of performing this evaluation in younger patients. than at home (19.4 %) or at school (13.8 %) (Fig. 4). If we analyse
the sites where the accidents occurred in each one of the age
The data of the Paediatric Trauma Registry in our Centre between groups, we can observe that in the youngest group this is princi-
January 1995 and April 2002 have been analysed; during this pally at home whereas, as age increases, accidents in the street
period, 2633 children who were admitted to our Centre after suf- and, to a lesser extent, at school, become the most frequent sites
fering some type of injury were included in the Registry. (Fig. 5).

The most common mechanism of the accident was a fall (35.6%),

Results
Accidents were more frequent in boys than in girls (68.5 % versus
31.5%). As may be seen in Fig. 1, this predominance was not con-
stant in all age groups: in the youngest, the incidence was practi-
cally the same in the two sexes but, with increasing age, there
was a progressive increase in the number of males. The number
of girls remained practically constant in all the age groups. The
proportion of each sex varied considerably depending on the
type of accident, as may be seen in Fig. 2.
The predominant age group was that of 12 ± 15 year old children
(36.8 %), and only 15.4 % of the children were under 4 years of age
(Fig. 3).
followed by road traffic accidents taken as a group (car, motor-
cycle and bicycle accidents and pedestrian casualties) which
accounted for 23.7 % (Fig. 6). 81.4 % of the children suffering a car
accident were not wearing any form of restraining device, and
56.2 % of those who suffered a motorcycle accident were not
wearing a crash helmet. There is a large group termed ªotherº
which includes accidental blunt trauma (collisions, sprains, di-
rect impact of objects, etc.), burns, electrocution, caustic injury,
bites, abuse, drowning, attempted suicide, etc. Analysis of the
different mechanisms of the accidents in the different age groups
shows that the accidents in the smallest children are principally
due to falls from a low height or from a considerable height (falls
from a height of over 1.5 m), and, to a lesser extent, car accidents;
as the children grow, bicycle accidents and sports-related inju-
ries increase in frequency (Fig. 7).

NavascuØs JA et al. Paediatric Trauma in Spain ¼ Eur J Pediatr Surg 2005; 15: 30 ± 37
 Fig. 3 Distribution of the children in the
100 different age groups.
90
80
70
60
Percent

50
40
30
20
10
0
Auto- Motor- Run- Bicycle Fall Fall from Assault Sports Others
mobile cycle over height

Original Article
Boys Girls

With regard to the severity of the injury, 14.7 % (n = 388) of the Home
children had a Paediatric Trauma Score (P.T.S.) £ 8 (Fig. 8) and of Others 506

Downloaded by: University of Pittsburgh. Copyrighted material.

375 School
these, 101 were considered as severe multiple trauma patients
Sports center 366
with an Injury Severity Score (I.S.S.) ³ 15 (Fig. 9). The most severe
113
injuries occurred in car accidents, pedestrian accidents, and mo-
torcycle accidents (Fig. 10). Playground
100
Analysis of pre-hospital care revealed that 1187 children were at- Country
103 Road
tended by health staff before their arrival at our Centre. In 88.9 %
85 Street
of the cases they were attended by a doctor (accompanied or not
980
by nursing staff), in 7.4 % by a nurse, and in 3.7 % by other person-
nel (paramedics, Red Cross volunteers). It was decided to transfer Fig. 4 Sites where the injuries occurred.
the child in specialised transport (normal or ITU ambulance) on 33
641 occasions (64.4 %), although in 486 (75.8 %) of these cases,
according to the results of our analysis, the child did not fulfill On analysis of the management of the 641 children transferred in
the criteria of severity (P.T.S. £ 8 or I.S.S. ³ 15). However, 219 of specialised transport, we found that, of the 323 who had suffered
these 1187 children who received assistance, did fulfill the crite- a head injury, a cervical collar was applied in only 47.4%
ria of severity and, of these, 41 (20.9 %) were not transferred in (n = 153). If we assess only the 73 severe head injuries (Abbrevi-
specialised transport. ated Injury Scale ³ 3) [1], this percentage rises to 54.8 % (n = 40).
In contrast, this falls to 33.8 % if we include all the head injuries

Fig. 5 Relative frequency of the different

100 sites where the injuries occurred in each age
Home
90 Street
group.
80 School
Country
70 Road
Playground
60
Percent

Sports center
50
40
30
20
10
0
0–3 4–7 8–11 12–15
(n =407) (n =556) (n =701) (n =969)
Years

NavascuØs JA et al. Paediatric Trauma in Spain ¼ Eur J Pediatr Surg 2005; 15: 30 ± 37
 Others out in 68.3% (n = 28). None of the 641 children transferred was
Sports 506 Automobile correctly immobilised with a paediatric immobilisation system.
Assault 356 155
40 Motorcycle
Fall 102 After arrival at the hospital, advanced life support was performed
from height Running-over in 26 children, usually involving endotracheal intubation. Nine of
168 204 the children intubated had a Glasgow £ 8 and had not been intu-
bated previously. With regard to basic life support measures, ve-
Bicycle nous lines were inserted in 349 children; of these, 155 had been
164
Fall attended previously without this being performed. Following our
938 Emergency Department protocol, all the children who had suf-
Fig. 6 Aetiology of the accidents. fered a high energy trauma, those who had lost consciousness
and those with a P.T.S. £ 8 were immobilised with a paediatric
immobilisation system and a cervical collar and lateral immobil-
attended by health staff before their arrival at our Centre. If we isers were applied. The diagnostic tests included plain x-rays in
Original Article

analyse the management of the children who fulfilled the criteria
of severity, we find that a venous access for fluid replacement
was inserted in 51.6 % (n = 80). In 77 cases this was a single pe-
ripheral venous line, in 2 cases two lines were inserted, and in
one case an intra-osseous access was used. Medication was ad-
ministered to 36.1% (n = 56), nasogastric intubation was per-
formed in 14.2 % (n = 22), and bladder catheterisation in 10.3 %
(n = 16). Of the 41 children in a state of coma during transfer
2351 children (89.3 %), blood tests in 496 (18.8 %), CT scan in 142
(5.4 %), and abdominal ultrasound in 97 (3.7 %). The most fre-
quent lesions were of the locomotor system (58.1%) and head in-
juries (34.9 %) (Fig. 11), and multiple injuries were diagnosed in
749 children (28.4 %).
1522 patients (57.8 %) underwent some type of surgical or ortho-
paedic procedure under general anaesthesia. 4.2 % of the children

Downloaded by: University of Pittsburgh. Copyrighted material.

(Glasgow Coma Scale £ 8), endotracheal intubation was carried required admission to the intensive care unit, where the mean

Fig. 7 Relative frequency of the different

100 aetiological mechanisms in each age group.
Automobile
90 Motorcycle
80 Run-over
Bicycle
70 Fall
Fall from
60
Percent

34 height
50 Sports
Assault
40
Others
30
20
10
0
0–3 4–7 8–11 12–15
(n =407) (n =556) (n =701) (n =969)
Years

1400 1200
1218 1189
1128
1200 1000
1031
1000
800
800
600
600
400
400 315

200 161
200
38 52
9 13 14 17 15 16
0 0
£0 1–2 3–4 5–6 7–8 9–10 11–12 £0 1–2 3–4 5–6 7–8 9–10 11–12
P.T.S. I.S.S.

Fig. 8 Paediatric Trauma Score of the patients. Fig. 9 Injury Severity Score.

NavascuØs JA et al. Paediatric Trauma in Spain ¼ Eur J Pediatr Surg 2005; 15: 30 ± 37
 Fig. 10 Severity of the different aetiologi-
cal mechanisms as a function of the I.S.S.,
18.1 length of stay and percentage of admissions
to the intensive care unit. ICU: intensive care
unit; I.S.S.: average Injury Severity Score;
L.O.S.: average length of stay.
14 11.7 10.8 10.6 10.7

12 8.8
8.5 6.7
10 7.2 6.9 7.1
2.5
6 1
8 8 0.3
7.2
3.9 % ICU
6 5.6
4.4 4.4
4 3.6 3.3 I.S.S.
3.2
2
L.O.S.

Original Article
0
Automobile Run-over Fall Assault

Motorcyle Bicyle Fall from height Sports

length of stay was 4.2 days (range 1 ± 59 days). The global mean
1600
length of stay was 4.4 days (range 1 ± 214 days). 1530

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1400
Some type of sequelae was detected in 36.4 % of the patients over 1200
3 years of age. An inverse correlation was observed between the 976
1000
P.T.S. and the incidence of sequelae, which was 100 % in the chil-
dren with a P.T.S. £ 4 (Fig. 12). 800
600
Total mortality was 0.5 % (n = 13) and 12.8 % in the group of pa- 400 297
tients with an I.S.S. ³ 15. All the children who died had a P.T.S. 170
200 141
< 4 and an I.S.S. > 20.
0
Head- Face Chest Abdomen Musculo-
cervical skeletal 35
Discussion
Fig. 11 Localisation of the lesions.
It is a well-known fact that boys suffer accidents more frequently
than girls and, according to the results of our analysis, this ap-
pears to be due to their greater propensity to be involved in
risk-associated activities since, as the child grows and acquires a of motorcycle passengers wearing a crash helmet was higher,
greater degree of freedom of action, the difference between the though still insufficient, particularly when this is, once again, an
sexes increases; in the 14 ± 15 year old age group, the ratio is obligatory measure in our country, even within built-up areas. In
greater than 4 : 1. Furthermore, it may be observed that the types these cases, it is usually the children who, in their parents ab-
of accidents in which male predominance is most marked are sence, decide to take the risk of not using such a simple, effective
sports-related injuries, falls from bicycles and motorcycle acci- and necessary safety measure, particularly since the driver is
dents. In the younger age groups, in which the children suffer in- usually the same person or a friend of similar age, in other words,
jury in situations created or not avoided by the persons accom- inexperienced. But it is once again the responsibility of the pa-
panying them, usually the parents, the frequency for each sex is rents, principally, to tell their children to use such elemental pre-
practically identical. These accidents are principally falls, falls ventive measures.
from heights, and car accidents.
As is known, the Paediatric Trauma Score (P.T.S.) is currently the
The data referring to the level of use of the security measures in most reliable anatomo-physiological index of severity available
road traffic accidents are frightening: the fact that more than for use in the child [19, 22]. However, it has been subject to
80 % of children admitted after suffering a car accident were criticism due to overtriage since, in a relatively large proportion
wearing no type of restraining device should make us think, of the children with a P.T.S. of 8 or less who, in principle, could be
since it is always the parents who are responsible for ensuring considered as serious, the magnitude of their lesions has not jus-
that the children are wearing such a device which, in our coun- tified this conclusion [2]. The undertriage, or the proportion of
try, is obligatory. Furthermore, this must be an approved device, children with a score higher than eight who do have severe inju-
adapted to the age and weight of the child. At this point it should ries has been persistently low in all the studies performed. In our
be stated that all the children in our series who died in a car ac- series, of the 388 children with a PTS £ 8, 101 were considered as
cident were travelling without using a retention device. The rate serious multiple injury patients, since they presented with an In-

NavascuØs JA et al. Paediatric Trauma in Spain ¼ Eur J Pediatr Surg 2005; 15: 30 ± 37

100
*All children with P.T.S. < 0 death
90
80
70
Impairments (%)
60
50
40
30
20
10
*
Original Article
0
<0 0 1 2 3 4 5 6 7
P.T.S.
jury Severity Score (I.S.S.) ³ 15, and 110 required admission to the
intensive care unit, indicating an overtriage of 72 ± 74%. How-
ever, if we consider that when dealing with children, an ISS of
10 or higher represents severe injury, the degree of overtriage
falls to 33%, since 261 of the 388 children had an ISS > 10. In con-
trast, we had zero undertriage in our series, since no child with a
P.T.S. of over 8 had serious lesions. Although excessive overtriage
leads to a greater use of resources than would theoretically be
necessary (transfer in specialised transport, performing diagnos-
tic tests, etc.), the absence of undertriage would guarantee that
all children with serious injury were attended and transferred
as such. However, this is based on the assumption that the P.T.S.
36 is used systematically as the index of severity in all care levels, a
circumstance which, as we shall see, does not occur in our set-
ting.
On this matter, it must be stated that serious deficiencies were
detected in the functioning of the pre-hospital care system. In
our setting, it appears that there is a disparity of criteria when
deciding which children must be transferred to a Paediatric
Centre by an appropriate means of transport, accompanied by
health professionals. It is known that a cervical collar must be
applied to any child who has suffered injury above the level of
the clavicles until cervical injury has been excluded ± all the
more important if the injury is of certain severity. We therefore
conclude that the management of this type of injury in our set-
ting is inadequate. As is known, any child who has suffered se-
vere injury, independently of the haemodynamic state, must
have one or preferably two vascular accesses inserted since signs
of shock may appear late and, when they appear, may signify de-
compensated shock. The fact that almost half of the children
with severe injury were transferred without even one venous
access is, at the least, worrying, as is the scant use of an intra-os-
seous line which, as we know, is an easy access to achieve in a
child, even in a state of shock when the veins are collapsed. It is
accepted that any child with a Glasgow £ 8 must have a protected
airway, preferably by endotracheal intubation. The fact that al-
most one third of the children in a state of coma were not trans-
ferred with a protected airway is equally significant.
NavascuØs JA et al. Paediatric Trauma in Spain ¼ Eur J Pediatr Surg 2005; 15: 30 ± 37
Fig. 12 Incidence of sequelae grouped
according to the P.T.S.
8 9 10 11 12
It is unimaginable that in our country a child with sepsis could be
treated only with occasional antibiotics or that a child with a ma-
Downloaded by: University of Pittsburgh. Copyrighted material.
lignant tumour could be treated with random chemotherapy
without following the available protocols. Why, therefore, is in-
jury, which, we should remember, causes as many deaths in in-
fancy as all other illnesses together, managed so inconsistently?
The answer is probably that there has been a great imbalance in
the provision of resources for materials, research, and the train-
ing of health personnel in the different fields. In our province,
there is a modern infrastructure for emergency health care in
the pre-hospital setting, with extensive material and human re-
sources in different provincial and state-run units. Sadly, how-
ever, this infrastructure has not been designed for the injured
child. We have thus found that the majority of the standard and
ITU ambulances do not have Philadelphia type cervical collars or
devices for spinal immobilisation specifically for children under
seven years of age despite the fact that the cost of a bone marrow
transplant for just one child could equip all the ambulances of
Madrid province with a these devices. The health personnel, with
a very high mean level of training, and certainly higher than in
many other countries, lacks the specific complementary training
concerning the management of the injured child.
From the results of our analysis it may be deduced that it is nec-
essary to insist on the educational measures for the general pop-
ulation in matters of prevention, on the training of health per-
sonnel, and on the equipping of the emergency teams, all aimed
at preventing or attenuating, in so far as is possible, the serious
consequences of injury in infancy, particularly since it has been
proven that half of the deaths may be prevented [5, 7]. The anal-
ysis of the data from our register has helped us to understand the
characteristics of the injured paediatric population in our set-
ting, to monitor the management of injury in the different care
levels and to develop prevention programmes. It has also en-
abled us to compare the results in terms of morbidity and mor-
tality with those of other centres with the aim of identifying
and correcting possible deficiencies in the health care system.
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37

NavascuØs JA et al. Paediatric Trauma in Spain ¼ Eur J Pediatr Surg 2005; 15: 30 ± 37