Injured Children Research Articles

USING EXISTING PAEDIATRIC PRE-HOSPITAL TRAUMA TRIAGE TOOLS TO IDENTIFY CHILDREN WITH SEVERE TRAUMATIC BRAIN INJURY–AN ANALYSIS OF NATIONAL TRAUMA REGISTRY DATA

Objectives & BackgroundSevere traumatic brain injury (TBI) in childhood causes long term neurodisability and death, though early neurosurgical intervention may improve outcome. Primary transfer to a neurosurgical centre reduces the...

Multiply Trauma in Children: Pulmonary Contusion does not Necessarily Lead to a Worsening of the Treatment Success

The aim of the study is to evaluate the impact of pulmonary contusion on the overall outcome in children with multiply injury. Retrospective review of 123 multiply injured children during a 10-year period (January 2000 to February 2010) who were admitted to the intensive care unit of a university affiliated, tertiary care pediatric trauma center. The diagnosis of pulmonary contusion (case group) was defined by the clinical context and the results of chest X-ray and blood gas analysis. Data were compared with a matched control group without the diagnosis of pulmonary contusion. Matching criteria were as follows: (1) age difference within 2 years; (2) sex; (3) similar injury pattern; (4) Pediatric Trauma Score (PTS) difference within 2 points; (5) Glasgow Coma Score (GCS) in two categories. The risk of pulmonary contusion must not be underestimated in multiply injured children. In our study, 49 of 123 patients (40%) showed signs of pulmonary contusion. A matched and pair analysis was performed in 46 patients (94%). Pulmonary contusion had an impact on the Pao2/ FIo2 ratio. It was significantly reduced in patients and caused insignificant extension of the ventilation time. Overall length of stay (LOS), LOS at pediatric intensive care unit, complication rate, mortality rate, and short-term outcome did not differ significantly between cases and controls. Pulmonary contusion alters gas exchange but does not appear to increase morbidity and mortality of pediatric patients with multiply injury. Interpretation may be limited by sample size.

Pediatric Trauma Team Activation: Are We Making the Right Call?

A regionalized trauma system must be tailored to the trauma epidemiology and the trauma care resources of the population it serves. Pediatric trauma system in Singapore differs from others because of its geographic compactness and relatively low incidence of severe trauma. The scarcity of polytrauma highlights the need of a reliable screening system to identify injured children who necessitate urgent transport to emergency department (ED) with pediatric resuscitation capacity as well as activation of trauma team upon their arrival. In this study, the validity of Pediatric Trauma Score (PTS), Glasgow Come Scale (GCS), and respiratory rate (RR) in identifying pediatric patients with major trauma and receipt of resuscitation is evaluated. After obtaining Institutional Review Board approval, a retrospective analysis was performed using data obtained from our trauma registry between January 2011 and December 2012. Information pertaining to the demographics, causative mechanism, and injury description, resuscitation, admitting disciplines, surgical intervention, and outcome were analyzed. The sensitivity and specificity of PTS, GCS, and RR to predict outcomes of interest are calculated. A total of 92 patients were recruited. From the 92 patients, 26 sustained major trauma, and 21 patients received ED resuscitation. The mean age was 4 years 9 months. Sensitivity and specificity of PTS ≤ 8, GCS ≤ 10, and abnormal RR for predicting major trauma were 61.5, 77.3; 26.9, 100; and 53.8, 60.6%; respectively. When the reliability to identify patients received ED resuscitation was evaluated the sensitivity and specificity of PTS ≤ 8, GCS ≤ 10, and abnormal RR were 90.5, 83.1; 28.6, 98.6; and 76.2, 66.2%; respectively. The parameters of PTS need to be further refined to improve its accuracy and minimize the undertriage rate. If a combined physiologic and anatomic scoring system such as PTS is used, other physiologic parameters such as GCS and RR may become redundant. The evaluation of the validity of PTS, GCS, and RR in predicting pediatric major trauma indicated poor reliability.

Admission rapid thrombelastography delivers real-time “actionable” data in pediatric trauma

PurposeAdmission rapid thrombelastography (rTEG) is a “real-time” clinical tool used to evaluate trauma-induced coagulopathy and direct hemostatic resuscitation. The relationship of rTEG to conventional coagulation tests (CCT) and early lifesaving interventions (LSI) in pediatric trauma is unknown. MethodsSeverely injured patients (age ≤14years) with an rTEG were retrospectively reviewed (8/1/2009–8/31/2011). Demographic and clinical information was collected. Spearman's correlation and regression models were used to evaluate rTEG with respect to CCT, early transfusion, LSI, and mortality. ResultsEighty-six patients were identified. The median age was 8years, and the median injury severity score (ISS) was 21. Activated clotting time (r=0.68), k-time (r=0.77), and α-angle (r=−0.75) showed strong correlation to PTT, and maximum amplitude (MA) (r=0.46) showed good correlation to platelet count (all p<0.001). When controlling for age, gender, and ISS, regression analysis showed that ACT, r-value, k-time, α-angle, and MA predicted red blood cell and plasma transfusion within 6h. MA (OR 0.82, 95% CI 0.70–0.96; p=0.018) was predictive of LSI. All rTEG values, except for LY30, predicted mortality. ConclusionAdmission rTEG correlates with CCT and predicts early transfusion, early LSI, and outcome in pediatric trauma. rTEG provides valuable data for goal-directed hemostatic resuscitation of critically injured children.

Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk

IntroductionA child's risk of developing cancer from radiation exposure associated with computed tomography (CT) imaging is estimated to be as high as 1/500. Chest CT (CCT), often as part of a “pan-scan,” is increasingly performed after blunt trauma in children. We hypothesized that routine CCT for the initial evaluation of blunt injured children does not add clinically useful information beyond chest radiograph (CXR) and rarely changes management. MethodsPediatric (<15 y) trauma team evaluations over 6 y at an academic Level I trauma center were reviewed. Demographic data, injuries, imaging, and management were identified for all patients undergoing CT. Effective radiation dose in milliSieverts (mSv) was calculated using age-adjusted scales. ResultsFifty-seven of 174 children (33%) undergoing CT imaging had a CCT; 55 (97%) of these had a CXR. Pathology was identified in significantly fewer CXRs compared with CCTs (51% versus 83%, P < 0.001). All 7/57 (12%) emergent or urgent chest interventions were based on information from CXR. In 53 children (93%), the CCT was ordered as part of a pan-scan, resulting in a radiation dose of 37.69 ± 7.80 mSv from initial CT scans. Radiation dose was significantly greater from CCT than from CXR (8.7 ± 1.1 mSv versus 0.017 ± 0.002 mSv, P < 0.001). ConclusionsClinically useful information found on CCT had good correlation to information obtained from CXR and did not change patient management, however, did add significantly to the radiation exposure of initial imaging. We recommend selective use of CCT, particularly in the presence of an abnormal mediastinal silhouette on CXR after a significant deceleration injury.

Emergency Management of Pancreatic Injury in a 5-Year-Old

Pediatric pancreatic injuries are less common than many other intra-abdominal organ traumatic injuries; failure to identify pancreatic injury during the emergency phase will result in delayed diagnosis, delayed treatment, and potentially poor health outcomes. Injured children may present to nontrauma center/nonpediatric hospitals or urgent care settings where practitioners may not be experienced in diagnosing and treating pediatric pancreatic injuries. This case study explores the medical course of a child with persistent abdominal pain after a fall from a horse. He was evaluated in a nonpediatric trauma center and was discharged home, continued with symptoms, presented to a different community emergency department, and then transferred to the emergency department at a Level 1 pediatric trauma center. Educating health care providers about pediatric pancreatic injuries in emergency or urgent care settings will help improve quality of care for injured children who are not initially evaluated in a pediatric specific hospital or trauma center.

A ‘knock on the noggin’

A 14-year-old mountain biker is brought by his parents to a local emergency care centre with a 5 cm facial laceration and a headache. He had been biking on one of the local trails alone and is a bit vague about the nature of the injury; “I must have fallen and cut myself on a rock”. He called his father on his cell phone at the time and arranged to meet him at the trailhead. He was wearing a helmet that was inspected by his father, which sustained no apparent impact. His Glasgow Coma Scale score is 15, and other than occasional yawning and apparent reduced attention, he seems fine. He is a bit tender over his right shoulder, and his jersey is dirty on this side. After cleaning and suturing the wound, he is discharged home. Learning points A high index of suspicion for concussion is always warranted. Not all head injuries involve brain injury (1), but enough do that it is always wise to consider this possibility. Concussion, a functional injury, accounts for most minor brain injuries. Only a few acutely injured children have structural abnormalities on imaging (2), and a subset may require neurosurgical intervention (2). Concussion may be quite subtle in presentation, particularly within the first 24 h (3). During the initial assessment, if there remains any doubt about the patient’s clinical status, choose to remove the patient from activity. ‘If in doubt, sit them out’. Over the next two days, he complained about a persistent headache, which felt worse when he climbed the stairs, and was not relieved with ibuprofen. He has been very irritable with his two younger siblings, finding them too loud. He called from school, complaining that his headache was markedly worse during math class, and he asked to come home, where he promptly fell asleep. His mother had him complete the symptom score of the Sport Concussion Assessment Tool 2 (SCAT2) (4), which she had downloaded from the Internet. He endorses 12/22 symptoms for a total score of 34/132. She is concerned and brings him to the evening clinic. He says he does not feel right. His general physical examination is normal, as is most of his formal neurological examination. Of note, he walks slowly, appears unsteady at times and has difficulty with tandem gait backwards with eyes open. Learning points The evaluation of concussion symptoms with the Sport Concussion Assessment Tool 2 (4) is recommended. A diagnosis of concussion is made with the appearance of symptoms (physical, emotional/behavioural, cognitive and sleep) following brain trauma (either direct or transmitted) (5) after alternative diagnoses have been considered. The current cornerstone of concussion management is physical and cognitive rest, until symptoms resolve (6). However, implementation is challenging, because rest is not easy for adolescents and even more problematic for younger children. The patient returns two weeks later, stating he has been headache-free for five days. He is attending school full-time as an honour-level student. His physical examination appears to be normal. Learning points Most adolescents’ concussions will resolve within several days (6),and 95% within three weeks (7). Because of the difficulty determining when concussions are ‘over’(8) and concern about children and adolescents’ vulnerability to brain injury, many agree on an asymptomatic period of several days before initiating return to play (6). Once medically cleared, a stepwise return to play exertional protocol should be followed with at least one day per step (5). In February 2012, a CPSP one-time survey showed that Canadian paediatricians frequently encounter patients with concussions. They use heterogeneous criteria to determine when patients become asymptomatic and variable return to play duration. More research and education are needed to ensure optimal management of concussions in the paediatric population.

Validity and reliability of the EQ-5D-3L™ among a paediatric injury population

BackgroundInjuries are a leading cause of death and disabilities for children and youth globally. Measuring the health related quality of life of injured children and youth can help gain understanding of the impact of injuries on this population; however, psychometric evaluation of health related quality of life tools among this population is lacking. The purpose of this study was to determine the construct validity of the EQ-5D-3L™ for use among a population of injured young people and to examine the reliability of different modes of administration including paper and pencil, online and telephone.MethodsIn total, 345 participants (aged 0 – 16) were recruited from a paediatric hospital in a large urban centre in British Columbia, Canada. To capture a variety of injury types and severity, patients were recruited from in-patient units and the emergency department. Data were collected at the time of recruitment and at one month post injury.ResultsRepeated measures analysis (rANOVA) showed that EQ-5D-3L™ scores were different before and after injury and significant between group differences (Visual Analog Scale: F = 4.61, p = 0.011; Descriptive Scale: F = 29.58, p < 0.001), within group differences (Visual Analog Scale: F = 60.02, p < 0.001; Descriptive Scale: F = 92.37, p < 0.001), and interaction between variables (Visual Analog Scale: F = 10.89, p < 0.001; Descriptive Scale: F = 19.25, p < 0.001) were detected, indicating its suitability for assessment of post-injury health related quality of life. Bland-Altman plots confirmed that few differences existed between modes of administration.ConclusionThe EQ-5D-3L™ is an appropriate instrument for collecting health related quality of life data among injured children and can be administered via paper-pencil, online or by telephone.

Does Young Age Merit Increased Emergency Department Trauma Team Response?

Introduction:To determine if increased trauma team response results in alterations in resource use in a population of children <6 years, especially in those least injured.Methods:We conducted a retrospective before and after study of children <6 years sustaining blunt trauma and meeting defined prehospital criteria. We compared hospitalization rates and missed injuries (injuries identified after discharge from the emergency department/hospital) among patients with and without an upgraded trauma team response. We compared the computed tomography (CT) rate and laboratory testing rate among minimally injured patients (Injury Severity Score [ISS] 6).Results:We enrolled 352 patients with 180 (mean age 2.7 ± 1.5 years) in the upgrade cohort and 172 (mean age 2.6 ± 1.5 years) in the no-upgrade cohort. Independent predictors of hospital admission in a regression analysis included: Glasgow Coma Scale <14 (odds ratio [OR]=11.4, 95% confidence interval [CI] 2.3, 56), ISS (OR=1.55, 95% CI 1.33, 1.81), and evaluation by the upgrade trauma team (OR=5.66, 95% CI 3.14, 10.2). In the 275 patients with ISS <6, CT (relative risk=1.34, 95% CI 1.09, 1.64) and laboratory tests (relative risk=1.71, 95% CI 1.39, 2.11) were more likely to be obtained in the upgrade cohort as compared to the no-upgrade cohort. We identified no cases of a missed diagnosis.Conclusion:Increasing the trauma team response based upon young age results in increased resource use without altering the rate of missed injuries. In hospitals with emergency department physicians capable of evaluating and treating injured children, increasing ED trauma team resources solely for young age of the patient is not recommended.

THE ESTABLISHMENT OF SCHOOL BASED INJURY SURVEILLANCE SYSTEM IN JIANGSU, CHINA

BackgroundChild injuries have been a significant public health problem worldwide. Although information technology is becoming the backbone of all injury surveillance systems, many child injury data collections are resource intensive,...

Inequalities in child injuries in Nepal: findings of a community based survey in Makwanpur

BackgroundThe lack of data on prevalence, risk factors, costs and consequences of child injuries has led to a lack of awareness and understanding of the problem in low income countries.AimTo...

Coaching our kids to fewer injuries: youth sports safety research

BackgroundParticipation in team sports builds kids' confidence, promotes teamwork, increases fitness, enhances social skills, and encourages healthy competition. Each year in the USA, 38 million children play organised sports. Yet,...

Factors Associated With the Interfacility Transfer of the Pediatric Trauma Patient

The goal of this study was to identify prehospital factors associated with increased likelihood of interfacility transfer of pediatric trauma patients. Such factors might serve as a basis for improvements in future field pediatric trauma triage guidelines. This was a retrospective cohort study of children aged 12 years or younger with blunt, penetrating, or thermal injuries who were transported by ground emergency medical services from the scene to the emergency department of a Level I, II, or III trauma center within the Denver metropolitan area from January 1, 2000, to December 31, 2008. Characteristics predicting subsequent interfacility transfer to a pediatric trauma center (PTC) were assessed. A total of 1673 patients were included in the analysis. Variables hypothesized to be most commonly associated with interfacility transfer were age, sex, mechanism of injury, body region of injury, and Glasgow Coma Scale score. The cohort included 1079 males and 593 females. Logistic regression analysis yielded the following as significant predictors of transfer: younger age (odds ratio [OR], 1.19; 95% confidence interval [CI], 1.15-1.25), lower Glasgow Coma Scale score (OR, 1.08; 95% CI, 1.01-1.16), the presence of burns (OR, 37.52; 95% CI, 7.3-191.7), non-accidental trauma (OR, 6.09; 95% CI, 2.44-15.25), falls (OR, 1.62; 95% CI, 1.06-2.48), other motor vehicle-related incidents (OR, 2.37; 95% CI, 1.08-5.19), abdominal injury (OR, 5.39; 95% CI, 2.31-12.55), head/neck injury (OR, 7.89; 95% CI, 4.21-14.77), limb injury (OR, 5.31; 95% CI, 2.78-10.16), and multiple injuries (OR, 13.01; 95% CI, 5.0-33.8). Factors highly associated with transfer of an injured child from a non-PTC to a PTC included younger age, burns, non-accidental trauma, head/neck injury, and multiple injuries in younger children. Further investigation is warranted to determine whether these factors may have applicability in future improvements in field pediatric trauma patient triage guidelines.

Early death and late morbidity after blood transfusion of injured children: a pilot study

Background/PurposeEarly postinjury death after packed red blood cell (pRBC) transfusion is attributed to uncontrolled hemorrhage and coagulopathy. The adverse immunomodulatory effects of blood transfusion are implicated in subsequent morbidity. We hypothesized that injured children requiring pRBC transfusion demonstrate patterns in outcome similar to those observed in adults. MethodsOur prospectively collected trauma registry was queried for demographics, treatment, and outcome (2006-2009). Outcomes of children who received pRBC transfusion were compared with those of age- and Injury Severity Score (ISS)–matched children who did not receive pRBC transfusion by both univariate and multivariable analysis. ResultsEight percent (43/512) of injured children received a pRBC transfusion: 20 early and 23 late. The likelihood of pRBC transfusion increased with increasing ISS (ISS <15, 2%; ISS 16-25, 17%; ISS >25, 72%). One-half of injured children who received an early pRBC transfusion died; however, most deaths were because of central nervous system injury. Both ventilator and intensive care unit days were increased in children who received pRBC transfusion as compared with those who did not. ConclusionEarly pRBC transfusion is associated with a high mortality in children. Late blood transfusion is associated with worse outcomes, although this relationship may not be causal. This pilot study provides evidence of an association between pRBC transfusion, morbidity, and mortality among injured children that warrants refinement in larger, prospective investigations.

Baumann Angle and Radial-Ulnar Overlap

Baumann's angle (BA) is the most common radiographic measurement used to assess coronal plane alignment of the distal humerus. However, it can vary greatly based on the x-ray beam angle, which can lead to multiple radiographs causing excessive radiation exposure, cost, and discomfort for the acutely injured child. The lateral capitellohumeral angle is a measure of sagittal plane alignment, and its variability has been reported. In this study, we sought to determine whether there were surrogate measures that could act as internal controls for the angle of the x-ray beam to give an accurate BA. Elbow radiographs from uninjured children stratified by age into 6 groups were reviewed. BA and lateral capitellohumeral angle as well as several predetermined measurements that could be potential surrogate measures for the angle of the x-ray beam were performed. Statistical significance was found between BA and radial-ulnar overlap (RUO), which was analyzed further and plotted in linear graph fashion. The Pearson correlation coefficient (0.58) between BA and RUO was significant at P=0.001. The average BA was 71±7.2 degrees (1 SD) and the average RUO was 0.34±0.26. The following linear graph equation was obtained to define the relationship between RUO and BA: BA=12.36 (RUO)+67. Further derivation gives us an equation to "correct" BA for a given RUO: corrected BA=measured BA-12.36 (RUO-0.34). Application of this formula lessened the SD of BA from 7.2 to 5.9 degrees and decreased the percentage of BA measurements outside of 1 SD from 30% to 14%. RUO is a reliable surrogate measure to control for the angle of the x-ray beam and improve the reliability when measuring BA that can be easily applied in the clinical setting. The ability to accurately correct the BA based on a given RUO gives the physician the confidence to adequately interpret imperfect radiographs in the emergency room setting and minimize repeat radiographs.

Patterns of pediatric injury in South Africa

Pediatric injuries are associated with significant morbidity and mortality, especially in low- and middle-income countries. Despite the magnitude of this burden, there is lack of data to characterize the etiology and risk factors associated with childhood injuries, especially in low- and middle-income countries. The aim of this article is to describe the demographics, mechanisms, and severity of injuries during a 10-year time period using hospital-based data in Cape Town, South Africa. Data from Childsafe South Africa's registry were used to study injured children younger than 13 years who presented with either intentional or unintentional injuries to the Trauma Unit of the Red Cross War Memorial Children's Hospital's (RCH) Causality Department between 1996 and 2007. Univariate and bivariate analyses were performed for demographic characteristics and injury mechanisms. Poisson regression analysis was used to analyze the age-adjusted annual incidence of injury presenting to RCH. Between 1997 and 2006, 62,782 children with a total of 68,883 injuries presented to RCH. The mean age was 5.4 years (standard deviation ± 3.5 years) and 61.7% were male. Mechanism of injury included falls (39.8%), road traffic injuries (15.7%), burns (8.8%), and assault (7.4%). The majority of injuries occurred in and around the home. Abbreviated injury severity scoring showed 60.2% of injuries were minor, 36.6% were moderate, and 3.2% were severe. Sixty-six deaths occurred in the trauma casualty department. Thirty-one percent of patients were admitted to the hospital; children who suffered burn and head injuries were more likely to require admission. Age, gender, mechanism, and severity of injury in pediatric populations have not been described elsewhere in South African national or sub-Saharan regional data. This retrospective, observational study uses Level II evidence to suggest the need for targeted interventions to address risk factors for pediatric injuries, emphasizing the importance of pediatric surveillance systems as a tool to study injuries in developing countries. Prognostic study, level II.

Congenital Brain Damage

The purpose of this study was to assess cognitive development in 26 children with congenital focal brain lesion and unilateral spastic cerebral palsy first diagnosed and followed up for rehabilitation at our institution. Mean intelligence quotients (IQs) were correlated not only to the different features of the cerebral lesions, but also to the different types of electroencephalographic abnormalities. We also examined individual scores. We found that about 70% of the children had values of Full-Scale, Verbal, and Performance IQs within the normal range. No differences were found between left and right injured children. Different Verbal IQ-Performance IQ profiles were observed. Larger lesions and some electroencephalographic features, mainly signal slowing/attenuation as signs of structural brain damage, were significantly associated with lower intellectual abilities. The role of other factors, including genetic and environmental background variability, as well as rehabilitative treatments, on cognitive sequelae in such patients was discussed.

Risk differences between children and adults in road traffic injuries

Our study attempted to describe the differences in circumstances, risk groups, and severity of road traffic injuries (RTIs) among injured children (1-15 years) and adults (≥16 years) coming to the tertiary-care hospital, Karachi, Pakistan. Past medical records from June 2006 to May 2007 of injured patients coming to the Emergency Department of the Aga Khan University Hospital, Karachi were reviewed. Data were recorded regarding the basic epidemiological features, hospital stay, body parts that are injured, and severity of injuries. Of 411 RTI patients, males outnumbered females by a ratio of 4 : 1 accounting for 81% (n = 333) of injured. Among pedestrians (82; 20%), females were injured more than males (38 vs. 16%; P < 0.01). When compared with adults, injured children were mostly pedestrians (18 vs. 36%; P = 0.01) and presented with severe Glasgow Coma Scale (GCS) (9 vs. 18%; P = 0.02). Among adults, most RTIs were caused by two wheelers crashing with four wheelers (16 vs. 19%; P = 0.01). Motor vehicle occupants (adjusted odds ratio: 3.04; 95% confidence interval: 1.382-6.668) were more likely to have severe GCS (GCS < 8) even after adjusting for injury severity. The study may assist local authorities in Karachi to prioritize interventions to address common injuries among those who are at a high risk for RTIs. Further quantitative and qualitative studies are needed to assess the factors leading to RTIs among pedestrians in Karachi.

Kindergarten teachers’ and their assistants’ knowledge of first aid in Slovenian kindergartens

Objective: Rapid physical and mental development in childhood also brings about a high risk of being injured. Since children spend a large amount of their time in kindergarten, there is a possibility that they would be injured while there. Design: A questionnaire for professionals was sent to a Slovenian kindergarten. Setting: The aim of this study is to analyze kindergarten teachers’ theoretical knowledge of first aid in Slovenian kindergartens. Methods: In a randomly selected sample ( N = 487), kindergarten teachers and assistants were included and polled about first aid topics. Results: The results show that teachers and assistants are familiar with the responsibilities related to first aid. In the case of burns, braises and fractures, they would act correctly, but in case of life threatening situations, for example cardiopulmonary resuscitation, intoxication, unconsciousness and asphyxia, less than 20% would properly provide first aid. No statistically significant differences were found between kindergarten teachers’ and assistants’ knowledge ( p &gt; 0.05), but statistically significant differences in age and work experience ( p &lt; 0.05) were found. Kindergarten teachers are aware of their responsibility for children’s lives and are well familiar with non-life threatening situations. In case of an emergency, most respondents would act incorrectly. The results also show that kindergarten teachers and their assistants overestimate their knowledge of first aid. Conclusion: Teaching in kindergarten requires a high level of first aid knowledge both because teachers are often faced with emergency situations and because teachers or assistants are the first to respond in most situations in which an injured child needs help.

The Association Between Insurance Status and Emergency Department Disposition of Injured California Children

This study examined the relationship between insurance status and emergency department (ED) disposition of injured California children. Multivariate regression models were built using data obtained from the 2005 through 2009 California Office of Statewide Health Planning and Development (OSHPD) data sets for all ED visits by injured children younger than 19 years of age. Of 3,519,530 injury-related ED visits, 52% were insured by private, and 36% were insured by public insurance, while 11% of visits were not insured. After adjustment for injury characteristics and demographic variables, publicly insured children had a higher likelihood of admission for mild, moderate, and severe injuries compared to privately insured children (mild injury adjusted odds ratio [AOR] = 1.36, 95% confidence interval [CI] = 1.34 to 1.39; moderate and severe injury AOR = 1.34, 95% CI = 1.28 to 1.41). However, uninsured children were less likely to be admitted for mild, moderate, and severe injuries compared to privately insured children (mild injury AOR = 0.63, 95% CI = 0.61 to 0.66; moderate and severe injury AOR = 0.50, 95% CI = 0.46 to 0.55). While publicly insured children with moderate and severe injuries were as likely as privately insured children to experience an ED death (AOR = 0.91, 95% CI = 0.70 to 1.18), uninsured children with moderate and severe injuries were more likely to die in the ED compared to privately insured children (AOR = 3.11, 95% CI = 2.38 to 4.06). Privately insured, publicly insured, and uninsured injured children have disparate patterns of ED disposition. Policy and clinical efforts are needed to ensure that all injured children receive equitable emergency care.