# Evaluating age-based vital sign cutoffs for pediatric trauma: a multicenter evaluation of the Japanese trauma data bank

## TL;DR

This study compares different vital sign thresholds for identifying major trauma in children and finds that PALS and empirically-derived criteria perform better than ATLS.

## Contribution

The study evaluates and compares the diagnostic accuracy of age-based vital sign criteria for pediatric trauma triage using a large multicenter dataset.

## Key findings

- PALS and empirically-derived criteria outperformed ATLS in identifying major trauma in children.
- For systolic blood pressure, PALS had higher sensitivity but lower specificity compared to empirically-derived cutoffs.
- Multivariable area under the ROC curves were 0.65 for PALS, 0.68 for empirically derived, and 0.63 for ATLS.

## Abstract

To evaluate differing vital signs criteria for the prediction of major trauma in children.

We conducted a multicenter retrospective cohort study including children (< 18 years) from the 2019–2022 Japan Trauma Data Bank. We compared Pediatric Advanced Life Support (PALS), Advanced Trauma Life Support (ATLS), and empirically-derived criteria for first-measured emergency department vital signs. The primary outcome was major trauma, defined as having an elevated Injury Severity Score and meeting Need for Trauma Intervention criteria (mortality, transfusion, intensive care unit admission, mechanical ventilation, and/or performance of surgery or interventional radiology procedure). We evaluated the diagnostic accuracy of each criterion and their performance in a multivariable logistic regression model.

Of 3,798 children included, 417 (11.0%) had major trauma. For heart rate, all criteria showed similar performance (sensitivity 42.2–45.3%, specificity 75.4–79.2%). For respiratory rate, ATLS had low sensitivity (10.6%, 95% confidence interval [CI] 7.8–13.9%) but high specificity (94.1%, 95% CI 93.2–94.8%). PALS and empirically-derived criteria had moderate sensitivity (~ 60%) and specificity (~ 60%). For systolic blood pressure, PALS had higher sensitivity (68.2%, 95% CI 63.5–72.7%) but lower specificity (42.5%, 95% 37.4–47.1%) than empirically derived cutoffs; ATLS had low sensitivity (12.5%, 95% CI 9.5–16.0%) but very high specificity (98.3%, 95% CI 97.8–98.7%). Multivariable area under the receiver operator characteristic curves were 0.65 for PALS, 0.68 for empirically derived, and 0.63 for ATLS.

PALS and empirically-derived criteria outperformed ATLS in identifying children with major trauma. These findings signal an opportunity to refine vital sign thresholds in pediatric trauma triage.

The online version contains supplementary material available at 10.1007/s00068-025-02985-6.