Mortality In Pediatric Trauma Research Articles

Prehospital time and mortality in pediatric trauma

PurposeThe “Golden Hour” of transportation to a hospital has long been accepted as a central principal of trauma care. However, this has not been studied in pediatric populations. We assessed for non-linearity of the relationship between prehospital time and mortality in pediatric trauma patients, redefining the threshold at which reducing this time led to more favorable outcomes.MethodsWe performed an analysis of the 2017–2018 American College of Surgeons Trauma Quality Improvement Program, including trauma patients age < 18 years. We examined the association between prehospital time and odds of in-hospital mortality using linear, polynomial, and restricted cubic spline (RCS) models, ultimately selecting the non-linear RCS model as the best fit.Results60,670 patients were included in the study, of whom 1525 died and 3074 experienced complications. Prolonged prehospital time was associated with lower mortality and fewer complications. Both models demonstrated that mortality risk was lowest at 45–60 min, after which time was no longer associated with reduced probability of mortality.ConclusionsThe demonstration of a non-linear relationship between pre-hospital time and patient mortality is a novel finding. We highlight the need to improve prehospital treatment and access to pediatric trauma centers while aiming for hospital transportation within 45 min.

Pre-hospital mortality among pediatric trauma patients in Nova Scotia.

Limited data exist on pre-hospital pediatric trauma mortality in Canada. The Nova Scotia Trauma Registry is a provincial population-based registry that captures data from the Medical Examiner Service. This study examined the characteristics of pediatric trauma patient mortality in the pre-hospital and in-hospital settings. We conducted a cohort study of major pediatric traumas recorded in our provincial database from April 1, 2001 to March 31, 2018. Characteristics of pre-hospital and in-hospital deaths were compared with t tests and Chi-square analyses. Multivariate regression modeling was used to identify predictors of pre-hospital mortality. The geographic distribution of pre-hospital trauma was assessed using choropleth maps. We identified 1,258 pediatric traumas, resulting in 217 deaths (137 pre-hospital, 80 in-hospital). Males accounted for 62.7% of fatalities. The 15-17 age group accounted for most deaths in both groups (pre-hospital 61.3%; in-hospital 41.3%). Injuries sustained in rural areas resulted in 74.7% of all deaths. For both groups, blunt trauma was the predominant injury type and motor vehicle collisions, the most prevalent injury mechanism. Patients who died pre-hospital had a higher mean age (13.3 vs. 10.7, p = 0.002) and a greater proportion were intentional injuries (23.4% vs. 15%; p = 0.02). Urban residency was more frequently observed in in-hospital deaths (57.5% vs. 36.5%, p < 0.001). Pre-hospital mortality was associated with increasing age (OR 1.1), higher injury severity score (OR 1.1), and intentional injury (OR 15.6). Over 10% of major pediatric traumas resulted in pre-hospital death, primarily from motor vehicle collisions in rural areas. Compared to in-hospital mortality, patients who died pre-hospital were older with more severe injuries and more likely to have intentionally injured themselves. These results underscore the importance for emergency physicians and EMS systems to consider geographic factors and injury patterns, advocate for improved injury prevention programs, mental health supports, and delivery of on-scene critical care services.

Which Trauma Severity Scores Are Useful in Predicting Pediatric Mortality?

Trauma is the leading cause of death in children. Several trauma severity scores exist: the shock index (SI), age-adjusted SI (SIPA), reverse SI (rSI), and rSI multiplied by Glasgow Coma Score (rSIG). However, it is unknown which is the best predictor of clinical outcomes in children. Our goal was to determine the association between trauma severity scores and mortality in pediatric trauma. A multicenter retrospective study was performed using the 2015 US National Trauma Data Bank, including patients 1 to 18 years old and excluding patients with unknown emergency department dispositions. The scores were calculated using initial emergency department parameters. Descriptive analysis was carried out. Variables were stratified by outcome (hospital mortality). Then, for each trauma score, a multivariate logistic regression was conducted to determine its association with mortality. A total of 67,098 patients with a mean age of 11 ±5 years were included. Majority of the patients were male (66%) and had an injury severity score <15 (87%). Eighty-four percent of patients were admitted: 15% to the intensive care unit and 17% directly to the operating room. The mortality at hospital discharge was 3%.There was a statistically significant association between SI, rSI, rSIG, and mortality (P < 0.05). The highest adjusted odds ratio for mortality corresponded to rSIG, followed by rSI then SI (8.51, 1.9, and 1.3, respectively). Several trauma scores may help predict mortality in children with trauma, the best being rSIG. Introduction of these scores in algorithms for pediatric trauma evaluations can impact clinical decision-making.

Association of Prehospital Transfusion With Mortality in Pediatric Trauma

Optimal hemostatic resuscitation in pediatric trauma is not well defined. To assess the association of prehospital blood transfusion (PHT) with outcomes in injured children. This retrospective cohort study of the Pennsylvania Trauma Systems Foundation database included children aged 0 to 17 years old who received a PHT or emergency department blood transfusion (EDT) from January 2009 and December 2019. Interfacility transfers and isolated burn mechanism were excluded. Analysis took place between November 2022 and January 2023. Receipt of a blood product transfusion in the prehospital setting compared with the emergency department. The primary outcome was 24-hour mortality. A 3:1 propensity score match was developed balancing for age, injury mechanism, shock index, and prehospital Glasgow Comma Scale score. A mixed-effects logistic regression was performed in the matched cohort further accounting for patient sex, Injury Severity Score, insurance status, and potential center-level heterogeneity. Secondary outcomes included in-hospital mortality and complications. Of 559 children included, 70 (13%) received prehospital transfusions. In the unmatched cohort, the PHT and EDT groups had comparable age (median [IQR], 47 [9-16] vs 14 [9-17] years), sex (46 [66%] vs 337 [69%] were male), and insurance status (42 [60%] vs 245 [50%]). The PHT group had higher rates of shock (39 [55%] vs 204 [42%]) and blunt trauma mechanism (57 [81%] vs 277 [57%]) and lower median (IQR) Injury Severity Score (14 [5-29] vs 25 [16-36]). Propensity matching resulted in a weighted cohort of 207 children, including 68 of 70 recipients of PHT, and produced well-balanced groups. Both 24-hour (11 [16%] vs 38 [27%]) and in-hospital mortality (14 [21%] vs 44 [32%]) were lower in the PHT cohort compared with the EDT cohort, respectively; there was no difference in in-hospital complications. Mixed-effects logistic regression in the postmatched group adjusting for the confounders listed above found PHT was associated with a significant reduction in 24-hour (adjusted odds ratio, 0.46; 95% CI, 0.23-0.91) and in-hospital mortality (adjusted odds ratio, 0.51; 95% CI, 0.27-0.97) compared with EDT. The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10). In this study, prehospital transfusion was associated with lower rates of mortality compared with transfusion on arrival to the emergency department, suggesting bleeding pediatric patients may benefit from early hemostatic resuscitation. Further prospective studies are warranted. Although the logistics of prehospital blood product programs are complex, strategies to shift hemostatic resuscitation toward the immediate postinjury period should be pursued.

Rising Mortality in Pediatric Self-Inflicted Firearm Trauma Associated With Distinct Anatomic Injury

IntroductionSelf-inflicted injuries are the second leading cause of pediatric (10-18 y old) mortality. Self-inflicted firearm trauma (SIFT) was responsible for up to half of these deaths in certain age groups. We hypothesized that SIFT prevalence has increased and is associated with specific demographics, injury patterns, and outcomes. Materials and methodsData were abstracted from the 2007-2018 American College of Surgeons (ACS) Trauma Quality Programs Participant Use Files (TQP-PUF). Pediatric (1-17 yold) victims of firearm violence were eligible. Age, race, gender, anatomic region, and intent were abstracted. Variables were analyzed using chi-squared tests, t-tests, and single-variate linear regression models. Temporal trends were analyzed using ANCOVA tests. Multivariate logistic regressions were conducted to identify factors influencing mortality. Significance was P < 0.05. ResultsThere were 41,239 pediatric firearm trauma patients (SIFT: 5.5% [n = 2272]). SIFT incidence increased over the 12-y period (2007 (n = 67) versus 2018 (n = 232), P < 0.05). SIFT was significantly associated with Caucasian race, 67% (n = 1537), teenagers, 90% (n = 2056), male gender, 87% (n = 1978), and a higher median injury severity score (ISS) than other intents of injury (SIFT: 20.0 (IQR: 9.0, 25.0) versus other: 9.0 (IQR: 1.0-13.0), P < 0.001). The SIFT mortality rate was 44% (n = 1005). On multivariate regression head gunshot wounds (OR: 21.1, 95% C.I.: 9.9-45.2, P = 0.001), and ISS (OR:1.1, 95% C.I.: 1.1-1.1, P = 0.001) were significantly associated with mortality. Compared to other intents, SIFT mortality rates increased at a higher annual rate (P < 0.001). ConclusionsComprehensive local and federal policy changes to reduce firearms access and increase pediatric mental health support may mitigate these injuries.

Pediatric trauma mortality in India and the United States: A comparison and risk-adjusted analysis

BackgroundThere is a paucity of research comparing pediatric risk-adjusted trauma mortality between high-income and low- and middle-income countries. This limits identification of populations and injury patterns for targeted interventions. We aim to compare independent predictors of pediatric trauma mortality between India and the United States (US). MethodsA retrospective cohort study was conducted for pediatric patients (age <18 years) in India's Towards Improved Trauma Care Outcomes (TITCO) project database and the US National Trauma Data Bank (NTDB) from 2013 to 2015. Demographic, injury, physiologic, anatomic and outcome data were analyzed. Multivariable regressions were used to determine independent predictors of mortality. Results126,678 pediatric trauma patients were included (India 3,373; US 123,305). Pediatric patients in India were on average significantly younger, with a higher median injury severity score (ISS), had lower systolic blood pressure, and suffered a higher case fatality rate (13.0% vs. 1.0%). When controlling for demographic, mechanism, physiologic, and anatomic injury characteristics, sustaining an injury in India was the strongest predictor of mortality (OR 22.70, 95% CI 18.70–27.56). On subgroup analysis, the highest relative odds of mortality in India was seen in children with lower injury and physiologic severity. ConclusionsRisk-adjusted pediatric trauma-related mortality is significantly higher in India compared to the US. The comparative odds of mortality are highest among children with lower injury and physiologic severity. This suggests that low-cost targeted interventions focused on standard timely trauma care, protocols, training and early imaging could improve pediatric injury mortality in India. Type of StudyRetrospective Prognosis Study Level of EvidenceII

Facility Size and Risk Factors for Mortality in Pediatric Trauma.

Pediatric trauma outcomes can vary across facilities, yet evidence on the relationship between facility bed size and pediatric trauma outcomes has been mixed. We aimed to identify how facility bed size might modify the impact of patient-level risk factors on mortality in pediatric trauma. We hypothesized that patient-level risk factors would have a stronger association with mortality at smaller trauma centers, and a weaker association with mortality at larger centers. We used deidentified data obtained from the 2017-2018 Trauma Quality Programs registry, including patients ages 0-18years of age who were admitted to the hospital. The primary outcome was in-hospital mortality. Facility bed size was dichotomized as large (>600 beds) vs small/medium (≤600 beds). Sensitivity analyses used 200 and 400 beds as alternative cutoffs. Interaction between facility bed size and patient characteristics was assessed using unadjusted logistic regression, with statistically significant interactions entered in a final, fully adjusted model. The analysis included 171810 patients (mean age 10 ± 5years; 65%/35% male/female), including 28% treated in a large hospital and 1.2% who died during the hospitalization. Controlling for trauma center level (or subsetting to pediatric trauma centers only), larger bed size did not reduce mortality risk associated with patient characteristics such as injury mechanism, injury severity, or patient demographics. Contrary to our hypothesis, greater facility bed size was not associated with reduced mortality risk associated with patient characteristics. Future studies are needed to identify hospital practices or characteristics that can attenuate the excess risk of known patient-level risk factors.

Teaching Trauma in Resource-Limited Settings: A Scoping Review of Pediatric Trauma Courses.

Injury remains an important cause of death and disability globally, with 95% of all childhood injury deaths occurring in low- and lower-middle-income countries (LMICs). Pediatric trauma training, tailored to the resources in LMICs, represents an opportunity to improve such outcomes. We explored the nature of course offerings in pediatric trauma in resource-limited settings. Seven databases were interrogated up to June 12, 2020, to retrieve articles examining pediatric trauma training in LMICs, as defined by the World Bank, without language restrictions. Independent authors reviewed and selected abstracts based on set criteria. Data from included studies was extracted and analyzed. An adapted Critical Appraisal Skills Programme checklist designed for cohort studies was used to assess the risk of bias. After screening 3960 articles for eligibility, 16 were included for final analysis. Course delivery methods included didactic modules, simulations, clinical mentorship, small group discussion, audits, assessments, and feedback. Knowledge acquisition was primarily assessed through pre/post-tests, clinical skills assessments, and self-assessment questionnaires. Twelve studies detailed course content, nine of which were based on the WHO Emergency Triage, Assessment and Treatment model, which is not specific to trauma. The other three studies involved locally developed pediatric trauma-focused training courses, including airway management, head trauma and cervical spine management, thoracic and abdominal trauma, orthopedic trauma, burn and wound management, and shock. Despite being essential to decreasing pediatric trauma morbidity and mortality worldwide, educational programs in pediatric trauma are not a widespread reality in low-and-middle-income countries. The development of accessible and efficient pediatric trauma education programs is critical for improving pediatric trauma quality of care.

Characteristics and outcomes of pediatric blunt renal trauma: a nationwide cohort study in Japan.

The aim of this study was to describe epidemiologic features of pediatric blunt renal trauma. We performed a retrospective analysis using the Japan Trauma Data Bank over 15years. We included patients younger than 18years with blunt renal trauma. We analyzed temporal trends and variations across age groups in patient characteristics, intervention, and in-hospital mortality. We also assessed factors associated with in-hospital mortality. We identified 435 pediatric patients with blunt renal trauma. Their median age was 14years and median Injury Severity Score (ISS) was 17. The most common mechanism of injury was traffic accident in all age groups. Nephrectomy was performed in 3.2%, and the overall in-hospital mortality was 4.6%, both of which showed decreasing trends. The most common mechanism of injury by age group was a pedestrian accident in infants/toddlers/preschoolers (43.5%), pedestrian accident in middle childhood (18.5%), bicycle accident in young teens (24.7%), and motorcycle accident in teenagers (41.2%). Sports-related injury was common in young teens (23.3%) and teenagers (15.2%). Factors such as ISS, shock, concomitant injury, and nephrectomy were associated with high in-hospital mortality. We described decreasing trends in nephrectomy and in-hospital mortality in pediatric blunt renal trauma and found traffic accident and sports-related injury were common in the pediatric population in Japan.

A Population-Based Study of the Incidence, Medical Care, and Medical Expenditures for Pediatric Traumatic Brain Injury

Traumatic brain injury (TBI) is one of the leading causes of pediatric trauma morbidity and mortality around the world. However, limited research exists regarding disparities in the incidence of TBI and medical care seeking behaviors and medical expenditures for TBI, particularly using population-based and nationally-representative data. The present study used the Medical Expenditure Panel Survey (MEPS) Panels 9-19 (2004-2015) to provide nationally-representative estimates for the civilian, non-institutionalized U.S. We examined differences in TBI incidence and associated medical care seeking behaviors and expenditures in relation to individual and family sociodemographic characteristics. From a total of 50,563 children in the MEPS Panels 9-19, we identified 449 children with TBI. For 82% of these children, medical treatment was sought. The estimated annual total expenditure associated with pediatric TBIs nationally was approximately $667 million, with mean expenditures per TBI being $1,532 and family out of pocket expenditures accounting for 8.3% of total expenditures. Race/ethnicity was the only significant factor associated with both medical care seeking behavior and total expenditures. The present study is among the first to compare pediatric TBI-related medical expenditures among different sociodemographic groups in the U.S. Our findings can inform future intervention research and policy-making from the perspectives of both epidemiological and behavioral sciences.

Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties.

Access to pediatric trauma care is highly variable across the United States. The purpose of this study was to measure the association between pediatric trauma center care and motor vehicle crash (MVC) mortality in children (<15 years) at the US county level for 5 years (2014-2018). The exposure was defined as the highest level of pediatric trauma care present within each county: (1) pediatric trauma center, (2) adult level 1/2, (3) adult level 3, or (4) no trauma center. Pediatric deaths due to passenger vehicle crashes on public roads were identified from the NHTSA Fatality Analysis Reporting System. Hierarchical negative binomial modeling measured the relationship between highest level of pediatric trauma care and pediatric MVC mortality within counties. Adjusted analyses accounted for population age and sex, emergency medical service response times, helicopter ambulance availability, state traffic safety laws, and measures of rurality. During the study period 3,067 children died in fatal crashes. We identified 188 pediatric trauma centers in 141 counties. Significant disparities in access to pediatric trauma care were observed. Specifically, 99% of pediatric trauma centers were situated in population-dense urban counties, while 28% of children lived in counties no trauma center. After risk adjustment, counties with pediatric trauma centers had significantly lower rates of pediatric MVC death than those with no trauma center: 0.7 versus 3.2 deaths/100,000 child-years; mortality rate ratio, 0.58; and 95% confidence interval, 0.39 to 0.86. In counties where pediatric trauma centers were absent, adult level 1/2 trauma centers were associated with comparable risk reduction. The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement. Epidemiological, level III; Care management, level III.

Pediatric Thoracic Trauma Mortality in Iraq and Afghanistan Compared to the United States National Trauma Data Bank.

The authors compared pediatric thoracic patients in the Joint Theatre Trauma Registry (JTTR) to those in the National Trauma Data Bank (NTDB) to assess differences in patient mortality rates and mortality risk accounting for age, injury patterns, and injury severity. Patients less than 19 years of age with thoracic trauma were identified in both the JTTR and NTDB. Multiple logistic regression, χ2, Student's t-test, or Mann-Whitney U test were used as indicated to compare the two groups. Pediatric thoracic trauma patients seen in Iraq and Afghanistan (n = 955) had a significantly higher mortality rate (15.1 vs. 6.0%, P <.01) than those in the NTDB (n = 9085). After controlling for covariates between the JTTR and the NTDB, there was no difference in mortality (odds ratio for mortality for U.S. patients was 0.74, 95% CI 0.52-1.06, P = .10). The patients seen in Iraq or Afghanistan were significantly younger (8 years old, interquartile ratio (IQR) 2-13 vs. 15, IQR 10-17, P <.01) had greater severity of injuries (injury severity score 17, IQR 12-26 vs. 12, IQR 8-22, P <.01), had significantly more head injuries (29 vs. 14%, P <.01), and over half were exposed to a blast. Pediatric patients with thoracic trauma in Iraq and Afghanistan in the JTTR had similar mortality rates compared to the civilian population in the NTDB after accounting for confounding covariates. These findings indicate that deployed military medical professionals are providing comparable quality of care in extremely challenging circumstances. This information has important implications for military preparedness, medical training, and casualty care.

Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in pediatric trauma.

Shock index and its pediatric adjusted derivative (pediatric age-adjusted shock index [SIPA]) have demonstrated utility as prospective predictors of mortality in adult and pediatric trauma populations. Although basic vital signs provide promise as triage tools, factors such as neurologic status on arrival have profound implications for trauma-related outcomes. Recently, the reverse shock index multiplied by Glasgow Coma Scale (GCS) score (rSIG) has been validated in adult trauma as a tool combining early markers of physiology and neurologic function to predict mortality. This study sought to compare the performance characteristics of rSIG against SIPA as a prospective predictor of mortality in pediatric war zone injuries. Retrospective review of the Department of Defense Trauma Registry, 2008 to 2016, was performed for all patients younger than 18 years with documented vital signs and GCS on initial arrival to the trauma bay. Optimal age-specific cutoff values were derived for rSIG via the Youden index using receiver operating characteristic analyses. Multivariate logistic regression was performed to validate accuracy in predicting early mortality. A total of 2,007 pediatric patients with a median age range of 7 to 12 years, 79% male, average Injury Severity Score of 11.9, and 62.5% sustaining a penetrating injury were included in the analysis. The overall mortality was 7.1%. A total of 874 (43.5%) and 685 patients (34.1%) had elevated SIPA and pediatric rSIG scores, respectively. After adjusting for demographics, mechanism of injury, initial vital signs, and presenting laboratory values, rSIG (odds ratio, 4.054; p = 0.01) was found to be superior to SIPA (odds ratio, 2.742; p < 0.01) as an independent predictor of early mortality. Reverse shock index multiplied by GCS score more accurately identifies pediatric patients at highest risk of death when compared with SIPA alone, following war zone injuries. These findings may help further refine early risk assessments for patient management and resource allocation in constrained settings. Further validation is necessary to determine applicability to the civilian population. Prognostic study, level IV.

Association between physician-staffed helicopter versus ground emergency medical services and mortality for pediatric trauma patients: A retrospective nationwide cohort study.

BackgroundHelicopter emergency medical services’ (HEMS) effectiveness for pediatric trauma patients remains unclear. We aimed to examine the relation between HEMS and reduced mortality in pediatric trauma patients.MethodsThis retrospective cohort study utilized data from the Japan Trauma Data Bank, a national multicenter clinical trauma database. Participants were aged <18 years, admitted between 2004 and 2015, and transported from the scene to the hospital by HEMS or ground emergency medical services (GEMS). We used a standardized mortality ratio (SMR) weight method, and fitted a marginal structural model to adjust for measured confounders. The SMR weight was calculated using the estimation of the propensity scores. A logistic regression model was used with the baseline independent variables to estimate the propensity score.ResultsOverall, 5,947 patients were identified in our study: 453 were transported by HEMS and 5,494 by GEMS. The mean injury severity score in the HEMS group was significantly higher than that in the GEMS group17.0 (Standard deviation = 11.0) vs 12.2 (Standard deviation = 9.2), p < .001. In-hospital mortality was higher in the HEMS group than that in the GEMS group in the unadjusted analysis (3.8% vs 1.3%, respectively; p < .001). After adjusting for covariates, HEMS transport was not associated with reduced hospital mortality. (odds ratio = 0.82, 95% confidence interval = 0.42–1.58).ConclusionsHEMS was not associated with reduced mortality among pediatric trauma patients compared with GEMS in this nationwide study. Further investigation is necessary to determine who clearly benefits from HEMS as compared to GEMS.

Comparison of Computed Tomography Use and Mortality in Severe Pediatric Blunt Trauma at Pediatric Level I Trauma Centers Versus Adult Level 1 and 2 or Pediatric Level 2 Trauma Centers.

Computed tomography (CT) is the criterion standard for identifying blunt trauma injuries in pediatric patients, but there are long-term risks of CT exposure. In pediatric blunt trauma, multiple studies have shown that increased CT usage does not necessarily equate to improvements in mortality. The aim of this study was to compare CT usage between level 1 pediatric trauma centers versus level 2 pediatric centers and adult level 1 and 2 centers. We performed a retrospective, multicenter analysis of National Trauma Data Bank patient records from the single admission year of 2015. Eligible subjects were defined as younger than 18 years with abdominal or thoracic blunt trauma, had an Injury Severity Scale score of greater than 15, and were treated at a level 1 or 2 trauma center. Data were then compared between children treated at level 1 pediatric trauma centers (PTC group) versus level 2 PTCs or adult level 1/2 trauma centers (ATC group). The primary outcomes measured were rates of head, thoracic, abdominal CT, and mortality. Data from ATC and PTC groups were propensity matched for age, sex, race, and Glasgow Coma Scale. There were 6242 patients after exclusion criteria. Because of differences in patient demographics, we propensity matched 2 groups of 1395 patients. Of these patients, 39.6% of PTC patients received abdominal CT versus 45.5% of ATC patients (P = 0.0017). Similarly, 21.9% of PTC patients received thoracic CT versus 34.7% of ATC patients (P < 0.0001). There was no difference in head CT usage between PTC and ATC groups (P = 1.0000). There was no significant difference in mortality between patients treated in the PTC versus ATC groups (P = 0.1198). Among children with severe blunt trauma, patients treated at level 1 PTCs were less likely to receive thoracic and abdominal CTs than those treated at level 2 pediatric or adult trauma level 1/2 centers, with no significant differences in mortality. These findings support the use of selective imaging in severe blunt pediatric trauma.

Prothrombin Time ratio can predict mortality in severe pediatric trauma: Study in a French trauma center level 1

BackgroundInjury results in more deaths in children than all other causes combined, but there is little data regarding the association of early coagulopathy on outcomes in pediatric patients with traumatic injuries. The aim of this study was to determine the optimal cut-off value for the Prothrombin Time ratio (PTr) and to show the diagnostic characteristics of the PTr to predict mortality. MethodsWe retrospectively included during 4 years all patients less than 16 years old referred to our trauma center for traumatic injury with ISS ≥9. ResultsA total of 272 children were included. Mean age was 9.4 ± 4.8 years and median ISS was 17 [interquartile range, 12 to 26]. Day 28 mortality was 6.7%. The optimal cut-off value in our population for predicting day 28 mortality was 1.24. Using this value, the sensitivity of PTr was 84%, specificity was 82%, positive likelihood ratio was 4.7, and negative likelihood ratio was 0.19. Early mortality (i.e., mortality at 24 h) was also well-predicted (1.0% versus 16.4%, p < .0001), as the need for massive transfuion. Similarly, patients with PTr ≥1.24 at admission presented with a higher rate of severe thoracic and abdominal trauma, higher ISS, higher likelihood of admission to an intensive care unit, longer hospitalization, and higher rate of significant procedure (e.g., surgery or embolization). ConclusionsTrauma-induced coagulopathy defined only by a PTr ≥1.24 could be used as a severity predictive marker and as a sensitive, specific, quick, and easy to use tool for admission triage of pediatric patients.

Addition of terlipressin to initial volume resuscitation in a pediatric model of hemorrhagic shock improves hemodynamics and cerebral perfusion.

Hemorrhagic shock is one of the leading causes of mortality and morbidity in pediatric trauma. Current treatment based on volume resuscitation is associated to adverse effects, and it has been proposed that vasopressors may be used in the pharmacological management of trauma. Terlipressin has demonstrated its usefulness in other pediatric critical care scenarios and its long half-life allows its use as a bolus in an outpatient critical settings. The aim of this study was to analyze whether the addition of a dose of terlipressin to the initial volume expansion produces an improvement in hemodynamic and cerebral perfusion at early stages of hemorrhagic shock in an infant animal model. We conducted an experimental randomized animal study with 1-month old pigs. After 30 minutes of hypotension (mean arterial blood pressure [MAP]<45 mmHg) induced by the withdrawal of blood over 30 min, animals were randomized to receive either normal saline (NS) 30 mL/kg (n = 8) or a bolus of 20 mcg/kg of terlipressin plus 30 mL/kg of normal saline (TP) (n = 8). Global hemodynamic and cerebral monitoring parameters, brain damage markers and histology samples were compared. After controlled bleeding, significant decreases were observed in MAP, cardiac index (CI), central venous pressure, global end-diastolic volume index (GEDI), left cardiac output index, SvO2, intracranial pressure, carotid blood flow, bispectral index (BIS), cerebral perfusion pressure (CPP) and increases in systemic vascular resistance index, heart rate and lactate. After treatment, MAP, GEDI, CI, CPP and BIS remained significantly higher in the TP group. The addition of a dose of terlipressin to initial fluid resuscitation was associated with hemodynamic improvement, intracranial pressure maintenance and better cerebral perfusion, which would mean protection from ischemic injury. Brain monitoring through BIS was able to detect changes caused by hemorrhagic shock and treatment.

Epidemiology and trend of US pediatric burn hospitalizations, 2003–2016

BackgroundThermal injury is a leading cause of unintentional pediatric trauma morbidity and mortality. MethodsThis retrospective analysis of the 2003–2016 Kids’ Inpatient Database (KID) included children <18 years old with a burn principal diagnosis. The objectives were to describe the trend of US pediatric burn hospital admissions and the patient and hospital characteristics of admitted children in 2016. The trends (2003–2012) and (2012–2016) were evaluated separately due to the 2015 implementation of International Classification of Diseases, Tenth Revision (ICD-10). ResultsThe population rate of pediatric burn admissions decreased by 4.6% from 2003 to 2012, but the proportion of admissions to hospitals with burn pediatric patient volumes≥100 increased by 63.9%. The overall mortality rate of hospitalized burn patients decreased by 48.1%. Median length of stay increased slightly for patients with a burn ≥20% total body surface area (TBSA) but decreased for patients with TBSA burn <20%. From 2012 to 2016, the population rate decreased by 13.4%. In 2016, an estimated 8160 children were admitted with a burn principal diagnosis, and 41.4% transferred in from other facilities. Children age 1–4 years were the most commonly admitted age group (49.7%). Patients with ≥20% TBSA burns accounted for 7.8% of admissions (95% confidence interval [CI]: 5.1–10.4%). Burn-related complications were documented in 5.9% of admissions (95% CI: 4.6–7.1%). ConclusionPediatric burn hospitalizations and burn-related mortality have decreased over time. The increases in transfers and admissions to hospitals with high pediatric burn volumes suggest increasing regionalization of care.

Pediatric trauma mortality: an ecological analysis evaluating correlation between injury-related mortality and geographic access to trauma care in the United States in 2010.

Trauma is the leading cause of mortality in the pediatric population>1year. Analyzing relationships between pediatric trauma-related mortality and geographic access to trauma centers (among other social covariates) elucidates the importance of cost and care effective regionalization of designated trauma facilities. Pediatric crude injury mortality in 49 United States served as a dependent variable and state population within 45minutes of trauma centers acted as the independent variable in four linear regression models. Multivariate analyses were performed using previously identified demographics as covariates. There is a favorable inverse relation between pediatric access to trauma centers and pediatric trauma-related mortality. Though research shows care is best at pediatric trauma centers, access to Adult Level 1 or 2 trauma centers held the most predictive power over mortality. A 4-year college degree attainment proved to be the most influential covariate, with predictive powers greater than the proximity variable. Increased access to adult or pediatric trauma facilities yields improved outcomes in pediatric trauma mortality. Implementation of qualified, designated trauma centers, with respect to regionalization, has the potential to further lower pediatric mortality. Additionally, the percentage of state populations holding 4-year degrees is a stronger predictor of mortality than proximity and warrants further investigation.

Aggressive Crystalloid Resuscitation Outcomes in Low-Severity Pediatric Trauma

BackgroundTrauma is the leading cause of death among children. Studies have found that insufficient intravenous (IV) fluid resuscitation contributes significantly to morbidity and mortality in pediatric trauma. While large-volume resuscitation represents a potential solution, overly aggressive fluid management may complicate hospitalizations and recovery. Through this study, we aim to evaluate the impact of aggressive fluid resuscitation on outcomes in pediatric trauma. Materials and methodsThis is a retrospective review utilizing our level I trauma center registry for pediatric patients aged <16 y admitted from 2014 to 2017. Patients transferred from our center within 24 h and those who arrived from outside hospitals were excluded. Patients who received blood product transfusions were excluded. Included patients were divided into two crystalloid groups: <60 mL/kg/24 h and ≥60 mL/kg/24 h. Outcome measures included ICU length-of-stay, length-of-hospitalization, complications, and mortality rate. ResultsStudy sample included 320 patients (<60 mL/kg/24 h = 219; ≥60 mL/kg/24 h = 101). The ≥60 mL/kg/24 h group was younger (9.95 versus 5.27, P = 0.0001). There were no significant differences in GCS on arrival, injury severity score, Abbreviated Injury Scale, Revised Trauma Scores, traumatic brain injury, and operative intervention between groups. Outcome measures showed there was no significant difference in 30-day readmission rate, complications, or mortality. Large-volume crystalloid resuscitation was associated with longer mean ICU length-of-stay (1.5 d versus 0.8 d, P = 0.004). ConclusionsIn this single-institution retrospective database analysis, large-volume crystalloid resuscitation (≥60 mL/kg) was associated with a significant increase in ICU length-of-stay without survival benefit. More research in the form of randomized trials will help determine the optimal rate for fluid resuscitation in pediatric trauma patients while weighing potential critical care complications.