Table 4.

Assessments and Examinations

CDE variable	CDE definition	Recommended instrument	Description of measure	Code list/permissible variable	Classification: core/supplemental/emerging
Module and data element name	Phrase or sentence to define the concept being measured	Name or acronym for the selected measure	Number and description of terms and subscale structure	Total range of scores	Indicate core/supplemental/emerging
Clinical Severity
Classification
Glasgow Coma Score (post-resuscitation) pediatric preferred	Glasgow Coma Score, best GCS obtained following resuscitation in the ED	GCS-I	3–15	Post-resuscitation	Core
Glasgow Coma Score (daily)	Glasgow Coma Score obtained on a daily basis during hospital stay. It should be best GCS on any given day	GCS-D	3–15	Best GCS during the last 24 h	Supplemental
Extracranial injuries	Extracranial injuries based on the Abbreviated Injury Severity Score	Extracranial injury	AIS ISS	AIS and calculated ISS on admission	Supplemental
Spine/spinal cord injury Pediatric Risk of Mortality (PRISM) score	Spinal column and or spinal cord injury Pediatric	Spinal injury PRISM		Radiographic signs/symptoms	Supplemental Supplemental
Second Insults			(Self-populating)
Hypoxia	Hypoxia	Hypoxia	Yes/no/unknown	Pao2 mm Hg O2 Saturation Oxygen percentage Time of measure First assessed vs. hourly	Core
Hypotension	Hypotension	Hypotension	Yes/no/unknown	SBP mm Hg	Core
Hyperthermia	Hyperthermia	Hyperthermia	Yes/no/unknown	oC	Core
Hypothermia	Hypothermia	Hypothermia	Yes/no/unknown	oC	Core
Hyperventilation	Hyperventilation	Hyperventilation	Yes/no/unknown	Paco2 mm Hg	Core
Cardiac arrest requiring CPR	Cardiac arrest	Cardiac arrest	Yes/no/unknown		Core
Seizures	Seizures	Seizures	Yes/no/unknown		Core
	Clinical seizures Status epilepticus	Clinical	Clinical/Non-convulsive		Supplemental
		Status epilepticus	Yes/no/unknown		Supplemental
Infection	Infection	Infection	Culture positive/suspected/unknown		Supplemental
Laboratory Data
Glucose	Glucose	Glucose	Serum values mg/dL	Thresholds: Hyperglycemia 180 mg/dL Hypoglycemia 80 mg/dL Critical 40 mg/dL Time of assessment: First Lowest	Supplemental
Hemoglobin	Hemoglobin	Hgb	Serum values g/dL	First Time of assessment: First Lowest	Supplemental
Vital Signs
Blood pressure	Blood pressure	MAP	MAP	Highest and lowest pressure over a given period; hourly recommended	Core
Intracranial pressure	Intracranial pressure	ICP	ICP	Highest and lowest pressure over a given period; hourly recommended	Core
Cerebral perfusion pressure		CPP	CPP	MAP, ICP	Core
Brain oxygenation, brain temperature, jugular venous oxygen				Hourly recording or high-frequency data capture	Emerging
Treatment
Hospital treatment	Amount of therapy and treatment necessary for control of ICP	Pediatric Intensity Level of Therapy Scale (PILOT)	PILOT	Scale 0–38, daily recording	Core

AIS, Abbreviated Injury Scale; ISS, Injury Severity Score; SBP, systolic blood pressure; Paco₂, partial arterial carbon dioxide pressure; MAP, mean arterial pressure.