Full text of DOI:10.1080/10903120290938346

HELICOPTER TRANSPORT OF PEDIATRIC VERSUS ADULT TRAUMA PATIENTS
Stephen J. Kotch, MD, Brian E. Burgess, MD
ABSTRACT
tal providers. Since the early 1970s, helicopter transport
has also seen rapid growth and popularity. Conflicting
reports exist, however, regarding the benefit and appro-
priate use of air transport for victims of trauma.2–5
Several studies have compared air versus ground
transportation of trauma patients, yet direct compari-
son of pediatric and adult trauma patients transported
by air is limited.3 Anecdotal experience suggests that
pediatric patients are often transported by helicopter
with less-severe injuries than adults. The purpose of
this study was to determine whether pediatric
patients transported directly from the accident scene
by air were less severely injured than adults.
Objective: Conflicting reports exist regarding the appropri-
ate utilization of helicopter transport for victims of trauma.
It has been suggested that adult patients are more severely
injured compared with pediatric patients when transported
by helicopter. The purpose of this study was to determine
whether injury severity and survival probability in pediatric
trauma patients were similar to those for adults when heli-
copter transport was utilized at a suburban trauma center.
Methods: The authors conducted a retrospective review of
all trauma patients transported by helicopter from the acci-
dent scene. Patients were identified from the Christiana
Care Health System trauma registry from January 1995 to
November 1999. Pediatric patients were defined as those
aged 15 years and younger. Data collected were utilized to
determine injury severity score (ISS), revised trauma score
(RTS), and survival probability. Results: Nine hundred
sixty-nine patients were transported; 143 were pediatric.
There was no statistical difference noted in ISS (14.21 adult,
12.76 pediatric; p = 0.1506) and RTS (7.23 adult, 7.31 pedi-
atric; p = 0.1832). Mean length of stay was less for the pedi-
atric group (7.5 days adult, 5.2 days pediatric; p = 0.008).
Survival probabilities were likewise similar for the two
groups, yet the difference met statistical significance (0.92
adult, 0.95 pediatric; p = 0.03). Conclusion: Pediatric
patients transported from the accident scene by helicopter
have similar ISSs and RTSs compared with adults. These
data suggest that prehospital selection criteria for the two
groups are similar. Key words: helicopter; emergency med-
ical services; trauma; triage; pediatrics; children; transport;
injury severity; survival probability.
METHODS
We conducted a retrospective review of all trauma
patients transported directly from the scene to a com-
munity-based Level 1 trauma center by helicopter.
The state of Delaware receives its primary air medical
support from the Delaware State Police Aviation
Division. The state police operate two aircraft (Bell
407, Bell Longranger) during the hours of 0800 to 2400.
Each aircraft is staffed by one pilot and a Nationally
Registered Emergency Medical Technician–Para-
medic, both of whom are police officers. An on-call
crew is available during the remainder of the time.
The Maryland State Police Aviation Division also
transports trauma victims to our facility and can pro-
vide backup for the Delaware State Police. Aircraft are
ideally dispatched at the time of incident alarm, or
upon request of the incident commander on scene.
Subjects were identified utilizing the Christiana
Care Health System trauma registry from January
1995 until November 1999. Pediatric patients were
defined as less than or equal to 15 years of age. Data
collected were used to determine mechanism of
injury, revised trauma score (RTS), injury severity
score (ISS), survival probability (SP), and hospital
length of stay (LOS). Patients were excluded if they
were transferred from another facility, or if data were
incomplete for analysis. Statistical analysis was per-
formed utilizing Mann-Whitney and Student’s t-test.
This study was approved by the Christiana Care
Institutional Review Board.
PREHOSPITAL EMERGENCY CARE 2002;6:306–308
Trauma is the primary cause of death in the first four
decades of life in the United States.1 Over the past 20
years, numerous advances have occurred in the care of
trauma patients. There have been increased utilization
of designated trauma centers, improvements in technol-
ogy, and advanced training of physicians and prehospi-
Received November 20, 2001, from Washington County Emergency
Physicians, Washington County Hospital (SJK), Hagerstown, Maryland;
the Department of Emergency Medicine, Emergency Medicine Residency
Program, Christiana Care Health System (SJK, BEB), Newark, Delaware;
and the Department of Emergency Medicine/Surgery, Thomas Jefferson
University School of Medicine (BEB), Philadelphia, Pennsylvania. Revision
received March 13, 2002; accepted for publication March 13, 2002.
RESULTS
Presented at the Society for Academic Emergency Medicine Regional
Meeting, York, Pennsylvania, March 2000; and the American College of
Emergency Physicians Scientific Assembly, Philadelphia, Pennsylvania,
October 2000.
During the study period, 969 patients were transport-
ed; 143 patients were pediatric and 819 were adult.
Seven patients were excluded from analysis due to
unknown age. There was no statistical difference
Address correspondence and reprint requests to: Stephen J. Kotch, MD,
11114 Shalom Lane, Hagerstown, MD 21742. e-mail: <kotchmd@aol.com>.
306

Kotch and Burgess HELICOPTER TRANSPORT OF CHILDREN VS ADULTS
307
TABLE 1. Results of the Study
noted in RTS (7.23 adult, 7.31 pediatric; p = 0.1832) and
ISS (14.21 adult, 12.76 pediatric; p = 0.1506). Mean LOS
was 7.5 days for adult patients and 5.2 days for pedi-
atric patients (p = 0.008) (Table 1). The SP was 0.92 for
adults versus 0.95 for pediatric patients (p = 0.03).
Blunt
Penetrating
Unknown
MechanismMechanismMechanism
of Injury
of Injury
of Injury
Age
≤15 years
>15 years
133
728
4
80
6
11
DISCUSSION
Total
Patients
Reviewed Minimum Maximum Mean
Helicopter transport of trauma patients has been both
praised and criticized. Conflicting evidence exists
regarding reduction in transport time, morbidity,
mortality, and hospital LOS.2–5 Pediatric patients rep-
resent approximately 10% of paramedic calls and
often present a unique challenge from both treatment
and transport perspectives.6
Age
Patients ≤15 years old
Patients >15 years old
All patients
143
819
962
<1
16
<1
15
97
97
8.55
38.57
34.45
Revised trauma score
Patients ≤15 years old
Patients >15 years old
All patients
129
790
919
<1
<1
<1
8
8
8
7.31
7.23
7.23
Moront et al. found that children transported by air
were often more seriously injured than children trans-
ported by ground when comparing groups by Glasgow
Coma Score (GCS), ISS, SP, and mortality.4 In their
study, however, 83% of patients transported by air had
an ISS of <15, a value previously associated with “seri-
ous” injury.1,7 The low mean ISS score we found for
both groups likewise suggests that the majority of
patients were not seriously injured. In contrast to this,
Tortella et al. noted no difference in ISS between pedi-
atric trauma patients transported by ground and air.3
As mentioned previously, data regarding pediatric
helicopter transport are sparse. Even more lacking is
the direct comparison between adult and pediatric
aeromedical transports. This current study closely
resembles the previously mentioned work by Tortella
et al. No difference was noted when comparing the
ISSs of adult and pediatric patients transported by hel-
icopter (p = 0.2023).3 They also noted no difference in
ISSs between pediatric patients transported by air and
ground, while adults appeared to have a significant
difference (18.0 vs 13.6, p < 0.0001).
Harrison et al. noted that pediatric patients were
transferred by air to Level 1 trauma centers more
quickly than adults with similar injuries.5 They meas-
ured aircraft activation times and noted a 34-minute
mean difference between adults and children with
similar GCSs. Whether this difference represents a
more expedient transfer of young patients or a relative
delay in the adult sample is unclear. These results may
also reflect the overall comfort level of the emergency
physician or surgeon in dealing with children who are
victims of trauma. Prior to undertaking this study, we
hypothesized that pediatric patients would have a sig-
nificantly lower RTS, ISS, and LOS than adults trans-
ported by air. We also felt that paramedic comfort
level with injured children would be less, thus leading
to more frequent transport by air. Our data, however,
did not suggest this.
Injury severity score
Patients ≤15 years old
Patients >15 years old
All patients
143
819
962
0
0
0
43
66
66
12.76
14.21
14.01
Length of stay
Patients ≤15 years old
Patients >15 years old
All patients
137
782
919
<1
<1
<1
45
165
165
5.22
7.53
7.15
guidelines, however, are largely subjective, which
leads to the question of how can we objectively evalu-
ate the need for air transport? In the urban setting, the
Helicopter Utilization Audit Committee has estab-
lished criteria for trauma scene flights: 1) >2 patients;
2) extrication >20 minutes; 3) heavy traffic patterns;
and 4) difficult access by ground vehicles.9 Rhodes et
al. found that unresponsiveness to verbal stimulus is
93% sensitive for predicting the need for air transport
in adult patients, as this was usually associated with
more severe injury.10 Moront et al. confirmed that GCS
is sensitive and specific for identifying patients who
may benefit from helicopter transport.4
One potential problem with studies such as this is
comparing adults and pediatric patients utilizing uni-
form scoring systems. The RTS is a weighed summa-
tion of the systolic blood pressure, GCS, and respira-
tory rate.9 This tool has been well validated in the
pediatric population and is the most widely used
triage scoring system in trauma.7,11 The ISS is a meas-
ure of multiple anatomic injuries. Each body region is
given a numerical score based on how severely
injured.7,12 These values are then squared and added
together to yield the final value. ISS scores of 15–20
have previously been suggested as indicating the need
for triage to a regional trauma center.1,7 The only prob-
lem is that this score is typically obtained from med-
ical records, and is of little help for prehospital per-
sonnel. However, the ISS has been shown to correlate
well with the RTS. It also has been well validated as a
Previous suggestions for appropriate helicopter use
have included severe injury, potential salvage, and
direct benefit from reduced transport time.8 These

308
PREHOSPITAL EMERGENCY CARE JULY / SEPTEMBER 2002 VOLUME 6 / NUMBER 3
predictor of trauma mortality, hospital LOS, intensive
care unit stay, and hospital billing.7,13,14
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Several key points should be taken from these find-
ings. There appears to be no difference between ISS
and RTS for adult and pediatric patients transported
by air. This may indicate that selection criteria for air
transport are the same for the two groups. However,
both groups had a mean ISS that did not indicate
“severe” injury. Whether this demonstrates mistriage
or overtriage needs further evaluation. It is also diffi-
cult to interpret the decreased LOS for the pediatric
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LIMITATIONS AND FUTURE STUDIES
This study is limited by its retrospective nature and
the relatively small number of pediatric patients com-
pared with the adults. Additionally, the data collected
are largely dependent on the medical documentation
of many individuals. Prospective studies following
patients flown from the trauma scene may aid in
improved data collection. Goals should be directed at
formulating and testing specific objective criteria for
trauma scene flights.
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Appropriate helicopter transport of urban trauma patients. J
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CONCLUSION
In our study population, pediatric patients transport-
ed directly from the trauma scene have ISSs and RTSs
similar to those of adults. Survival probability is
slightly greater, while hospital length of stay is less for
pediatric patients. These data suggest that the prehos-
pital selection criteria for helicopter transport is simi-
larly utilized for the two groups. Overtriage within
both groups remains potentially problematic until
more refined criteria for air transport are established.