The authors compared air and ground transport to a level I pediatric trauma center to assess the effectiveness of helicopter transport of injured children. They also performed a retrospective assessment of triage criteria and utilization patterns for helicopter transports. The sample comprised 3,861 children who were admitted (consecutively) to an urban level I pediatric trauma center during a 4-year period and who were transported by emergency medical services. TRISS probability of survival (P2),z, and W scores were used to compare outcomes of ground and air transports. An absolute value of z greater than 1.96 indicates a statistically significant difference in mortality rate; the W statistic represents the number of survivors more than expected per 100 patients treated. Receiver operator characteristic (ROC) curves were used to identify optimal triage criteria, using P6 < .95 to define children who potentially could benefit from air transport. The triage criteria were applied to the air transport group to determine overtriage rates. Nearly 75% of the children arrived directly from the scene of injury. Those transported by air were more severely injured, as shown by significant differences in the mean Glasgow Coma Scale (GCS), P6, Injury Severity Score, and mortality rate. The better survival rate for children transported by helicopter was indicated by a TRISS z score of 2.81, compared with a z score of 0.31 for those transported by ambulance. The W statistic for the children transported by air was 1.11. ROC analysis identified GCS < 12 and heart rate > 160 beats per minute as optimal air triage criteria; these yielded 99% sensitivity and 90% specificity. Using these criteria, approximately 85% of air transports would be considered overtriage. The authors conclude that (1) helicopter transport was associated with better survival rates among urban injured children; (2) pediatric helicopter triage criteria based on GCS and heart rate may improve helicopter resource utilization without compromising care; and (3) current air triage practices result in overuse of helicopters in approximately 85% of flights.