National Pediatric Trauma Registry Research Articles

Epidemiology of pediatric trauma in the Kingdom of Bahrain: a national pediatric trauma registry pilot study

BackgroundA pediatric trauma registry for the Kingdom of Bahrain would be a novel public health tool for the Bahraini health system. The aim of this study was to explore the epidemiology of pediatric trauma at the national level by describing the distribution of pediatric injury in the Kingdom, and quantifying the burden of injury shouldered by the study population.MethodsThis multicenter observational cross-sectional study was conducted in Bahrain using data from the Pediatric Trauma Registry (PTR), which was a short-term paper-based prospective trauma registry that collected data over a three-month period in 2018. PTR was based in the pediatric emergency departments (ED) of the three national referral hospitals in the Kingdom. By simultaneously collecting data from all three trauma hospitals in the country, it was assumed that during the data collection period all major pediatric trauma patients in the country would be captured by the study, and that the data collected would provide national estimates of trauma. Inclusion criteria for the study was any individual under the age of 14, that arrived at the ED seeking care for intentional and unintentional injuries.ResultsA total of 1328 patients were included in the study. Sixty-nine percent of patients were treated and discharged from the ED, 30.5% were admitted to the hospital, admitted for surgery, or seen by a specialist, and 0.5% were declared deceased. The percentage of patients documented as unrestrained during Motor Vehicle Collisions (MVC) was 92.3%, and amongst those involved in MVC, 12% were ejected from the cabin of the vehicle.ConclusionsThere are significant implications that this study holds for policy implementation and practice surrounding injury prevention in the Kingdom of Bahrain. Low seatbelt utilization and the high proportion of ejection amongst MVC victims warrant immediate public health policy implementation, including enforcement of seat belt laws, strengthening of the traffic court system, and awareness campaigns for MVC prevention. Additionally, pediatric drowning prevention programs centered on constant adult supervision, pool isolation fencing, personal flotation devices, and swimming education should be created to address the mortality attributable to drowning in this study.

Epidemiology of brachial plexus injury in the pediatric multitrauma population in the United States

The aim of this study was to estimate the prevalence of brachial plexus injury (BPI) in pediatric multitrauma patients. The National Pediatric Trauma Registry was queried using the ICD-9 code 953.4, injury to brachial plexus, to identify cases of BPI. The patient demographics, mechanism of trauma, and associated ICD-9 diagnoses were analyzed. Brachial plexus injuries were identified in 113 (0.1%) of the 103,434 injured children entered in the registry between April 1, 1985, and March 31, 2002. Sixty-nine patients (61%) were male. Injuries were most often caused by motor vehicle accidents involving passengers (36 cases [32%]) or pedestrians (19 cases [17%]). Head injuries were diagnosed in 47% of children and included concussion in 27%, intracranial bleeds in 21%, and skull fractures in 14%. Upper-extremity vascular injury occurred in 16%. The most common musculoskeletal injuries were fractures of the humerus (16%), ribs (16%), clavicle (13%), and scapula (11%). Spinal fractures occurred in 12% of patients, and spinal cord injury occurred in 4%. The Injury Severity Score ranged from 1 to 75, with a mean score of 10, and 6 patients (5%) died as a result of injuries sustained during a traumatic event. Brachial plexus injuries occur in 0.1% of pediatric multitrauma patients. Motor vehicle accidents and pedestrians struck by a motor vehicle are the most common reasons for BPIs in this population. Common associated injuries include head injuries, upper-extremity vascular injuries, and fractures of the spine, humerus, ribs, scapula, and clavicle.

Pediatric Disaster Preparedness: The Potential Role of the Trauma Registry

Improving trauma care and preparing for a disaster require data collection and analysis. Trauma registries capture data for research, measure trauma system outcomes, and support quality improvement through assessment of the appropriateness and effectiveness of the trauma system. The purpose of this article is to evaluate the role of trauma registries in disaster planning for the pediatric population by: (1) describing the history and current state of pediatric trauma registries; (2) providing examples of functioning trauma registries and their application to assist in disaster planning; and (3) a summary of the applicability to pediatric disaster planning as well as recommendations for future efforts. The National Pediatric Trauma Registry was discontinued in 2002. A detailed plan and design have been developed for the National Trauma Registry for Children; however, the funding has not been available to implement. The National Trauma Data Bank is the largest repository of trauma records in the United States; however, it has not focused specifically on pediatric data collection. The most highly reported use of trauma registry data for studying mass casualties and disaster planning has been conducted outside of the United States and related to terrorist attacks. Aggregating existing data from state trauma registries or using the National Trauma Data Bank may facilitate development of statistical models to help predict survival, injury patterns, and important physiological thresholds. However, representative pediatric-specific trauma registry data are needed to obtain an adequate sample size in pediatric population to extrapolate data to represent the scale of a disaster.

Application of International Classification Injury Severity Score to National Surgical Quality Improvement Program Defines Pediatric Trauma Performance Standards and Drives Performance Improvement

The American College of Surgeons National Surgical Quality Improvement Program is becoming a core methodology to define performance as a ratio of observed to expected events. We hypothesized that application of this using International Classification of Injury Severity Score (ICISS) for individual patient risk stratification to a group of hospitals contributing data to the National Pediatric Trauma Registry (NPTR) would apply objective evidence of actual injuries to define an expected standard and identify performance outliers. Using a blinded code, children entered into phase III of the NPTR were aggregated by treating hospital. Individual patient ICISS survival probability (Ps) were calculated using survival risk ratios (SRR) derived from the phase II NPTR dataset (n = 53,253). For each center, sample size, observed mortality, and ICISS Ps were calculated. Probability of mortality (Pm) was computed as 1 - Ps. Logistic regression was used to develop a predictive model for mortality. Logit transformation of Pm was performed to adjust for the skew of minor injury in children and reduce overestimation of low Pm fatalities. Mean Pm was computed for each center and multiplied by its volume to determine expected frequency. Observed to expected ratio (O/E) and 95% confidence interval were calculated to define expected performance and outliers above or below 1 SD of the mean O/E. Patients treated at 30 pediatric trauma centers (mean volume = 451 +/- 258/patients per center) were evaluated. Mean O/E was 1.001 with SD = 0.404. Twenty-two centers fell within the reference range; O/E of 12 centers exceeded 1, suggesting performance below expectation. Trauma center volume, as reflected by sample, did not correlate to O/E performance. Application of ICISS Ps from a national pediatric benchmark population simplifies determination of expected mortality necessary to compute the expected component of National Surgical Quality Improvement Program. Analysis of these ratios of expected to observed mortality demonstrates variance among centers, defines performance against peers using the same benchmarks, and can drive performance improvement based on the objective evidence of injury diagnoses actually encountered.

The Impact of Injury Coding Schemes on Predicting Hospital Mortality After Pediatric Injury

Accurate adjustment for injury severity is needed to evaluate the effectiveness of trauma management. While the choice of injury coding scheme used for modeling affects performance, the impact of combining coding schemes on performance has not been evaluated. The purpose of this study was to use Bayesian logistic regression to develop models predicting hospital mortality in injured children and to compare the performance of models developed using different injury coding schemes. Records of children (age < 15 years) admitted after injury were obtained from the National Trauma Data Bank (NTDB) and the National Pediatric Trauma Registry (NPTR) and used to train Bayesian logistic regression models predicting mortality using three injury coding schemes (International Classification of Disease-9th revision [ICD-9] injury codes, the Abbreviated Injury Scale [AIS] severity scores, and the Barell matrix) and their combinations. Model performance was evaluated using independent data from the NTDB and the Kids' Inpatient Database 2003 (KID). Discrimination was optimal when modeling both ICD-9 and AIS severity codes (area under the receiver operating curve [AUC] = 0.921 [NTDB] and 0.967 [KID], Hosmer-Lemeshow [HL] h-statistic = 115 [NTDB] and 147 [KID]), while calibration was optimal when modeling coding based on the Barell matrix (AUC = 0.882 [NTDB] and 0.936 [KID], HL h-statistic = 19 [NTDB] and 69 [KID]). When compared to models based on ICD-9 codes alone, models that also included AIS severity scores and coding from the Barell matrix showed improved discrimination and calibration. Mortality models that incorporate additional injury coding schemes perform better than those based on ICD-9 codes alone in the setting of pediatric trauma. Combining injury coding schemes may be an effective approach for improving the predictive performance of empirically derived estimates of injury mortality.

Application of Electronic Surveillance and Global Information System Mapping to Track the Epidemiology of Pediatric Pedestrian Injury

To compare the epidemiology of pediatric pedestrian injury in Jacksonville, FL to national trends, to analyze geographic distribution of these injuries, and to analyze pedestrian injury severity trends over time. Hospital emergency department and trauma registry data were analyzed for calendar year 2002 to define the incidence by age of vehicular pedestrian injury (Classification of Diseases--9th Revision--Clinical Modification E-code 814.7) in children less than 18 years old. The group was then stratified into the cohort living in the urban center (health zone 1-HZ1), and all other children in the region served by our state designated regional pediatric trauma referral center. To identify specific areas of cluster within and outside HZ1, FL Department of Highway Safety and Motor Vehicles (DHSMV) pedestrian crash data were analyzed for years 2002 to 2004. Global information system (GIS) mapping was performed based upon crash data geographic information. A recently deployed electronic injury surveillance system that combines both emergency department and trauma registry databases was then used to perform a similar analysis for calendar year 2006, which was the second of a 2-year program of enhanced prevention education specifically focused on the children and families of HZ1. This data were complied with 2006 DHSMV data to identify any decrease or change in GIS distribution of 2006 crashes compared with those of 2002. The 71 total crashes encountered during the 2002 included 21 children (30%) with injury severity that required admission to the trauma service. Children from HZ1 represented 34% of the 2002 cohort (N = 24). Comparison of victim age distribution to a national sample recorded in the National Pediatric Trauma Registry demonstrated a statistically significantly higher proportion of adolescents injured in Jacksonville. Epidemiologic evaluation of a larger sample of DHSMV data for 2002 to 2004 identified 236 crashes, in which males constituted a majority (64.4%). Fall was the largest season with 30.9% of incidents. Most crashes occurred from 1 pm to 8 pm (61.4%) and were distributed predominantly during weekdays. A major portion of crashes occurred at nonintersections (40.3%). As indicated in the 2002, cohort adolescents aged 11 to 15 were the largest age group struck (35% for 2002, 48% for 2002-2004). GIS mapping revealed a high density of crashes in the urban core of northwest Jacksonville. Data from 2006 identified 74 children struck by vehicles, including only 9 (12%) who required admission to the trauma service. The proportion of HZ1 victims remained the same (35%); however no HZ1 child required admission to the trauma service. The overall incidence was unchanged either in age distribution or occurrence within HZ1. Comparison of 2006 GIS data to 2002 highlights a persistence of pedestrian incidents in north and west components of urban Jacksonville. Analysis of 2006 DHSMV data reveal similar epidemiologic trends to 2002 to 2004. Although Jacksonville is similar to national trends in terms of gender, hour, day, and location of pedestrian injury, it differs from previous reports in terms of seasonality and the high proportion of adolescents struck. The effect of enhanced education appears to have diminished injury severity, although comparison of GIS plots clearly demonstrates that effective control will require changing environmental factors. Moreover, this report mandates further investigation and prevention efforts specifically targeting adolescents in urban areas.

Surgical quality improvement: a simplified method to apply national standards to pediatric trauma care

Background The emerging “pay for performance” national initiative mandates the development of valid metrics for risk stratification and performance assessment. The International Classification Injury Severity Score (ICISS) predicts survival from injury and is calculated as the product of survival risk ratios (SRRs) for a patient's 3 worst injuries. Survival risk ratios are derived as the proportion of fatalities for every International Classification of Diseases, Ninth Edition, Clinical Modification, diagnosis in a “benchmark” population. We hypothesized that the ICISS prediction model derived from the National Pediatric Trauma Registry (NPTR) would accurately predict mortality in an independent sample from a single pediatric trauma center (PTC) and could be applied to the NSQIP methodology to analyze performance. Methods The ICISS survival probabilities (Ps) were calculated for PTC patients using SRRs computed from 102,608 NPTR records. Records with a single diagnosis and Ps of 1 were excluded from the analysis. Receiver operator characteristics analysis (ROC) was used to evaluate the accuracy of Ps to predict mortality. The Hosmer-Lemeshow statistic was used to determine the degree that the NPTR-derived expected probabilities matched the observed mortality profile at the PTC. Program performance from 2000 to 2004 was then evaluated using Ps adjusted by logit transformation to predict expected mortality (E) for each year cohort. Observed mortality divided by expected mortality (O/E) was calculated for each year group to compare PTC performance to the NSQIP standard of one. The influence of injury severity on these results was determined by evaluating the correlation between O/E and mean Ps of each year cohort. Results A total of 1523 records were analyzed. The ROC area under the curve (AUC ) for Ps was .947 (confidence interval, .934-.957). The Hosmer-Lemeshow statistic ( χ 2 = 5.102; df = 8; P = .747, not significant) indicated the model fit the data well. Adjusted O/E ratio after logit transformation of Ps for the PTC demonstrated initial performance slightly below standard (1.000778) followed by performance better than expected for the subsequent 4 years (range, .6466-.9784). The ratio of observed (O) to expected (E) demonstrated no correlation to mean Ps ( r 2 = .378; P = .208). Conclusion These data validate the application of injury diagnosis derived survival probabilities as objective metrics for determining performance using the NSQIP methodology. Incorporation of these objective predictors of expected outcome to calculation of the risk adjusted O/E ratio enables trend analysis of program performance over time. The lack of significant correlation between O/E and mean Ps demonstrates that NSQIP does indeed reflect process of care while adjusting for severity of patient pathologic condition.

Risk Stratification Simplified: The Worst Injury Predicts Mortality for the Injured Children

The International Classification Injury Severity Score (ICISS) uses anatomic injury diagnoses to predict probability of survival (Ps) computed as the product of the survival risk ratios (SRR) of the three most severe injuries. SRRs are derived as the proportion of fatalities for every International Classification of Diseases-9th Revision-Clinical Modification diagnosis in a "benchmark" population. Pediatric-specific SRRs were computed from 103,434 entries in the National Pediatric Trauma Registry. We hypothesized that ICISS was a valid pediatric outcome predictor, and that the child's most severe injury; i.e., the lowest SRR, is the major driver of outcome, which can be used alone to predict survival. Receiver operator characteristic analysis was used to assess the predictive validity of ICISS. SRRs derived from 53,235 phase II patients were used as the training set to calculate the Ps for 50,199 phase III children comprising the test set. The survival probability (Ps) computed from the standard three diagnoses was compared with that computed from only the worst injury (lowest SRR). Records with a single diagnosis or Ps of 1, indicating no mortality potential, were excluded from the analysis. Nagelkerke pseudo R2 defined what proportion of the predicted Ps was the effect of the worst injury alone versus the traditional Ps. A total of 25,239 records with at least two diagnoses with SRRs indicating risk of mortality were analyzed. The area under the receiver operator characteristic curve for traditional Ps was 0.935, compared with 0.932 for that calculated using only the lowest SRR. The difference of 0.003 was not significant (z = 1.061, p = 0.2888, NS). Nagelkerke pseudo R2 for the lowest SRR was 0.455 compared with 0.462 for the traditional three diagnosis Ps, which shows that the majority of Ps predictive power is related to the single injury with the lowest SRR. Further analysis demonstrated that this effect was related to frequency of coexistent injuries with no mortality risk rather than definable difference in severity. These data validate ICISS as predictive of pediatric injury survival. The dominant effect of the worst injury reflects an epidemiologic characteristic of pediatric trauma that will identify specific injuries for best practice analysis and focused injury prevention.

Mortality in Adolescent Girls vs Boys Following Traumatic Shock

Female sex imparts a survival benefit after traumatic injury in children. Review of patients (aged 0-17 years) included in the National Pediatric Trauma Registry between April 1994 and September 2001. Multiple logistic regression was used to analyze the effect of sex on mortality, adjusting for age, severity of injury (New Injury Severity Score and Pediatric Trauma Score), severity of head or extremity injury, injury mechanism, intent, and comorbidities. Subset analysis focused on severely injured children (New Injury Severity Score >or= 16) with shock (systolic blood pressure <or= 90 mm Hg, adjusted for age). Adjusted odds of mortality between sexes. Of 46,859 children, 67% were boys. Girls had a higher crude mortality rate than boys (3.1% vs 2.7%, respectively; P < .05), but after adjustment, no significant difference was found in the odds of mortality between sexes (odds ratio, 1.16; 95% confidence interval, 0.89-1.37). Among children meeting the definition of severe injury with shock (n = 697), mortality was 39%. On regression analysis, sex did not predict outcomes in prepubescent children (aged <or= 11 years; n = 532; 95% confidence interval, 0.56-1.22). However, among adolescents (aged 12-17 years), girls demonstrated significantly decreased odds of death when compared with equivalently injured boys (odds ratio, 0.38; 95% confidence interval, 0.14-0.90; n = 165). Adolescent girls exhibit lower mortality than boys following traumatic shock. This effect is not seen in prepubescent children. These findings suggest that hormonal differences may play a role in the sex-based outcome disparities following traumatic shock in children.

Dirt Bikes and All Terrain Vehicles: The Real Threat to Pediatric Kidneys

Recent reviews show that bicycles are the major cause of significant renal injury with few injuries occurring during contact sports. All-terrain vehicles are also responsible for significant pediatric renal trauma. We determined whether dirt bikes and all-terrain vehicles cause more significant renal injuries than contact sports. A retrospective review of our pediatric trauma database revealed 115 consecutive patients treated for renal trauma from 2000 to 2005. A total of 20 bicycle injuries occurred, including 6 on dirt bikes. A total of 13 all-terrain vehicle injuries occurred, including 4 involving rollovers. A total of 12 contact sport injuries occurred, including 2 during pick-up games. The mean grade of renal injury was compared among the mechanisms, with grades III-V considered high grade. In descending order of renal injury the mechanisms were dirt bike (2.8), all-terrain vehicle rollover (2.8), bicycle (2.3), all-terrain vehicle (2.1), contact sports (1.8) and organized contact sports (1.4). Dirt bikes and all-terrain vehicle rollovers caused significantly greater renal trauma than organized contact sports (2.8 vs 1.4, p = 0.007 and 0.02, respectively), whereas overall bicycle and all-terrain vehicle accidents resulted in similar renal trauma grades compared to those of all contact sports. The 2 high grade renal injuries during contact sports occurred during pick-up football games without protective gear. Physician advice regarding children with a solitary kidney should include avoiding dirt bikes and all-terrain vehicles. Efforts to limit all-terrain vehicle use in children younger than 16 years would decrease the risk of significant renal injury in this population more effectively than limiting contact sports participation.

Validation of a Relative Head Injury Severity Scale for Pediatric Trauma

Brain injury is the most important independent predictor of mortality and morbidity in pediatric trauma. The Glasgow Coma Score (GCS) is the commonly used clinical instrument to assess brain injury. However, the GCS or one of its components is often not applicable in children under a certain age or cannot be computed reliably because of the patient's condition or the circumstances surrounding resuscitation efforts. This limits its usefulness in statistical models of trauma outcomes, which rely on complete data collection and entry into trauma registries. This study provides evidence validating use of a relative head injury severity scale (RHISS) derived from available International Classification of Diseases, 9th Revision (ICD-9) diagnosis codes to stratify degree of head injury. The patient population was derived from the National Pediatric Trauma Registry (NPTR;1994-2001). Survival Risk Ratios (SRRs) were computed for each head injury ICD-9 code. ICD-9 diagnosis codes related to head injury were then assigned to a RHISS category based on duration of loss of consciousness, location of skull fracture, or both: 0 = none; 1 = mild; 2 = moderate, or 3 = severe head injury. Analysis of variance compared mean SRRs across RHISS categories. Each patient was then assigned to a RHISS category based on their single worst ICD-9 head injury code. Logistic regression analysis was used to predict mortality based on New Injury Severity Score (NISS), whether the patient had been intubated, RHISS, and the Abbreviated Injury Score (AIS) for head and neck injuries. GCS score was missing for 96% of nonsurvivors in the NPTR. Mean SRRs differed significantly (p < 0.001) among ICD-9 codes assigned to each RHISS category, as follows (Mean +/- SD): RHISS (0) = 0.93 +/- 0.16; RHISS (1) = 0.89 +/- 0.22; RHISS (2) = 0.85 +/- 0.26; RHISS (3) = 0.55 +/- 0.35. Logistic regression identified RHISS as an independent significant predictor (p < 0.01) of mortality. RHISS is a valid index of degree of head injury in the pediatric trauma population. Unlike GCS, RHISS is more likely to be available in trauma registries, and can be computed from administrative data. RHISS provides a feasible and valid method for quantifying the degree of brain injury in statistical models of pediatric trauma outcome.

Black Children Experience Worse Clinical and Functional Outcomes After Traumatic Brain Injury: An Analysis of the National Pediatric Trauma Registry

Recent studies suggest racial disparities in the treatment and outcomes of children with traumatic brain injury (TBI). This study aims to identify race-based clinical and functional outcome differences among pediatric TBI patients in a national database. A total of 41,122 patients (ages 2-16 years) who were included in the National Pediatric Trauma Registry (from 1996-2001) were studied. TBI was categorized by Relative Head Injury Severity Score (RHISS) and patients with moderate to severe TBI were included. Individual race groups were compared with white as the majority group. Differences between races in functional outcomes at discharge in three domains-speech, locomotion, and feeding-were determined using multiple logistic regression. Cases were adjusted for age, sex, severity of head injury (using RHISS), severity of injury (using New Injury Severity Score and Pediatric Trauma Score), premorbidities, mechanism, and injury intent. A total of 7,778 children had moderate or severe TBI with or without associated injuries. All races had similar demographics. Hispanics (n=1,041) had outcomes comparable to whites (n=4,762). Black children (n=1,238) had significantly increased premorbidities, penetrating trauma, and violent intent. They also had higher unadjusted mortality and longer mean intensive care unit and floor stays. After adjustment, there was no difference in the odds of death between black and white children. However, black patients were more likely to be discharged to an inpatient rehabilitation facility and had increased odds of possessing a functional deficit at discharge for all three domains studied. Black children with traumatic brain injury have worse clinical and functional outcomes at discharge when compared with equivalently injured white children.

Evaluation of the relationship between mechanism of injury and outcome in pediatric trauma.

Most prehospital triage strategies are based on physiologic, anatomic, and mechanism-related variables. Although previous studies have suggested the value of physiologic and anatomic triage criteria, the predictive capacity of mechanism of injury has been questioned. The purpose of the current study was to evaluate the relationship between mechanism of injury and resource utilization and outcome among injured children treated at trauma centers. The relationship between mechanism of injury and mortality and resource utilization (need for operative care, total and ICU length of stay) was analyzed using the records of pediatric patients (age <15 years) included in the National Pediatric Trauma Registry between 1995 and 2001. Significant variability in the outcome, resources requirements, and need for inpatient rehabilitation after discharge were observed among the mechanisms analyzed. Mechanisms such as firearm injuries were more likely to be severe and require significant trauma center resources, whereas other mechanisms such as falls related to stairs were more likely to result in injuries that were less severe and require relatively few resources. A proposed framework is presented into which mechanisms are stratified according to severity of injury (high vs. low severity) and need for trauma center resources (high vs. low requirement). Mechanism of injury is associated with the need for trauma center care but this association is highly dependent on the measure used to determine appropriateness of triage.

Patient and Injury Characteristics in Abusive Abdominal Injuries

To identify patient and injury characteristics associated with suspected child abuse in the setting of blunt abdominal trauma. We extracted from the National Pediatric Trauma Registry phases 2 and 3 (October 1995 to April 2001; N = 106,135) all cases of blunt abdominal injury, excluding motor vehicle injuries, in patients aged 0 to 4 years. Independent variables included age, mortality, nutritional status, and injury type. The dependent variable was suspected child abuse. Six hundred sixty-four cases were analyzed. The median age of patients was 2.6 years; 11.4% were undernourished. The 3 most common mechanisms of injury were suspected child abuse (40.5%), fall (36.6%), and struck-not child abuse (9.7%). Hepatic injury (46.1%) was the most common intra-abdominal injury, followed by splenic (26%), hollow viscous (17.9%), and pancreatic (8.6%) injuries. Eighty-four percent of deaths were related to suspected child abuse. There was a greater proportion of children with suspected child abuse in every patient and injury characteristics studied than all other mechanisms combined. In a regression model including age, undernourishment, pancreatic injury, hollow viscous injury, traumatic brain injury, and mortality, all variables were significantly associated with suspected abuse. Hollow viscous injury had the highest odds ratio (OR, 9.5; confidence limits, 5.7, 15.8), whereas traumatic brain injury had the lowest (OR, 3.6; confidence limits, 2.4, 5.6). Young children with severe pancreatic or hollow viscous injuries or severe abdominal injuries in the context of either brain injury or undernourishment should be evaluated for the possibility that these injuries resulted from abuse. Increasing the awareness of the possibility of child abuse associated with a set of injury characteristics may allow for more consistent and complete medical evaluation.

African American children experience worse clinical and functional outcomes after traumatic brain injury: An analysis of the national pediatric trauma registry

African American children experience worse clinical and functional outcomes after traumatic brain injury: An analysis of the national pediatric trauma registry

Predicting Hospital Mortality Among Injured Children Using a National Trauma Database

The purpose of this study was to develop a model that accurately predicts mortality among injured children based on components of the initial patient evaluation and that is generalizable to diverse acute care settings. Important predictive variables obtained in an emergency setting are frequently missing in even large national databases, limiting their effectiveness for developing predictions. In this study, a model predicting pediatric trauma mortality was developed using a national database and methods to handle missing data that may avoid biases that can occur restricting analyses to complete cases. Records of pediatric patients included in the National Pediatric Trauma Registry (NPTR) between 1996 and 1999 were used as a training set in a logistic regression model to predict hospital mortality using vital signs, Glasgow Coma Scale (GCS) score, and intubation status. Multiple imputation was applied to handle missing data. The model was tested using independent data from the NPTR and National Trauma Data Bank (NTDB). Complete case analysis identified only GCS-eye and intubation status as predictors of mortality. A model based on complete case analysis had good discrimination (c-index = 0.784) and excellent calibration (Hosmer-Lemeshow c-statistic, 6.8) (p > 0.05). Using multiple imputation, three additional predictors of mortality (systolic blood pressure, pulse, and GCS-motor) were identified and improved model performance was observed. The model developed using multiple imputation had excellent discrimination (c-index, 0.947-0.973) in both test datasets. Calibration was better in the NPTR testing set than in the NTDB (Hosmer-Lemeshow c-statistic, 9.2 for NPTR [p > 0.05] and 258.2 for NTDB [p < 0.05]). At a probability cutoff that minimized misclassification in the training set, the false-negative and false-negative rates of the model were better than those obtained with either the Revised Trauma Score (RTS) or Pediatric Trauma Score using data from the NPTR testing set. Although the false-positive rates were lower with the RTS using data from the NTDB, the false-negative rates of the proposed model and the RTS were similar in this test dataset. Using multiple imputation to handle missing data, a model predicting pediatric trauma mortality was developed that compared favorably with existing trauma scores. Application of these methods may produce predictive trauma models that are more statistically reliable and applicable in clinical practice.

Out-of-Hospital Pediatric Cardiac Arrest: Where Are We Now and Where Do We Need to Go?

Out-of-hospital pediatric cardiac arrest is difficult to study, and I congratulate the authors in this month’s Annals of Emergency Medicine for their thorough systematic review of the current state of knowledge. With due respect to the investigators who contributed to this knowledge base and to the authors of this report, I suspect that many Annals readers may feel uncertain about what we really know about out-of-hospital pediatric cardiac arrest and, more importantly, how that knowledge can be used to improve outcome. Other than knowing that outcome after out-of-hospital pediatric cardiac arrest is poor, this systematic review illustrates important limitations of this type of review because of the limitations of the studies on which it is based. The author’s initial goals of clearly identifying gaps in our knowledge and determining the effects of commonly used interventions on outcome are difficult to deduce from the available data. Although 41 studies and more than 5,300 children are included in the identified studies, a minority of these studies could be evaluated when looking at the association of specific interventions on outcome, such as bystander cardiopulmonary resuscitation or the association of the initial rhythm with outcome in various patient causal categories. As the authors discuss under study limitations, observational studies often use inconsistent study designs. This inconsistency is clearly true for cardiac arrest studies and is illustrated by the more than 7-fold variation in the reported incidence of cardiac arrest (2.6 to 19.7 cases per 100,000 pediatric population) and the surprising results about outcome after traumatic-induced arrest. As the authors correctly note, however, the method of patient inclusion into the National Pediatric Trauma Registry database likely included children who were not in cardiac arrest. Once children in these National Pediatric Trauma Registry reports were excluded, traumatic cardiac arrest resulted in poor outcome, as expected. Throughout the more than 20 years of reports included in this review, imprecise inclusion and exclusion criteria were used. The pediatric Utstein guidelines for reporting data were not published until 1995 and were incorporated to various degrees in subsequent reports. In addition to variable inclusion criteria, different outcome definitions were used. Furthermore, the most commonly used functional outcome used was designed

Airbag deployment and improperly restrained children: a lethal combination.

Airbag deployment is an acknowledged mechanism of serious trauma in children involved in motor vehicle crashes. From a review of national databases, we determined the number and types of fatal and nonfatal injuries to children caused by airbag deployment and child restraint system use. We also reviewed the relevant literature and provide information useful for caregivers and health care professionals in hopes of reducing future injuries. We retrospectively reviewed 263 reported cases in which airbag deployment caused fatal or nonfatal injuries in children from reports released by the National Highway and Transportation Safety Administration and the National Pediatric Trauma Registry. Data were collected from January 1993 to December 2002 and imported into a database program for analysis. Of the 263 pediatric injuries caused by airbag deployment, 159 were fatal, and 104 were nonfatal. The peak incidence occurred in 1998, when 58 children were reported injured. Head injuries were most frequent, involving 170 children (64.6%), followed by spinal injuries, involving 100 children (38.0%). For children in their first year of life, head injuries were the sole mechanism of fatality. Of all children studied, only six (2.3%) were properly restrained. Airbag deployment in motor vehicle crashes is a well-recognized mechanism of morbidity and mortality in the pediatric population. Most injuries include trauma to the head and spine, which can have significant long-term consequences. Although the reported incidence of such injuries is decreasing, many children are improperly restrained. In our study, only 2.3% of children were properly restrained, suggesting that proper child restraint and seating position could have prevented most injuries.

Pelvic Fractures in Children

Pelvic fractures in children represent a unique set of patients for several reasons. Pediatric pelvic fractures are relatively uncommon and the long-term consequences of these fractures and their associated injuries often have a substantial impact on these patients for the rest of their lives. There is significant controversy regarding the appropriate approach toward the management of these injuries. Nevertheless, there is substantial variability in the orthopaedic management of pediatric pelvic fractures, which warrants a closer investigation. A good starting point for addressing some of these issues is to explore the relationship between practice patterns and patient outcomes. More specifically, a study exploring the relationship between the type of centers that treat these unique fractures and patient outcomes can yield some insightful information. In an effort to address these issues, the authors used the National Pediatric Trauma Registry to conduct a retrospective analysis of this unique pediatric population. The main outcome of interest focused on mortality. With respect to patient information, the independent variables involved demographics (gender, age, race), type of injury (penetrating, blunt, crush), presence of head injury, injury severity indices (Injury Severity Score [ISS], Glasgow Coma Scale), and the Functional Independence Measure. After adjusting for confounding and interaction effects between these variables, only ISS and the type of hospital were determined to be significant in predicting survival.

A NEED FOR REEVALUATION OF SPORTS PARTICIPATION RECOMMENDATIONS FOR CHILDREN WITH A SOLITARY KIDNEY

We sought to evaluate the incidence and outcome of blunt renal injury in children by mechanism of injury. These data could then be used to provide the basis for more rational recommendations to parents and physicians regarding participation in sporting activities. We analyzed data on 49,651 pediatric trauma cases collected by 92 trauma centers as part of the National Pediatric Trauma Registry from 1995 to 2001. Cases involving renal injury were isolated and the data were stratified according to age, sex and injury, as well as procedures required for treatment and outcomes. Of 49,651 pediatric trauma patients 813 incurred renal injury. There were 516 males and 291 females, and sex was not documented in 6 children. Average age was 10.6 years. There were no reports of a solitary kidney. In the sports group there were 4 nephrectomies, which were associated with sledding (2), skiing (1) and rollerblading (1), and 2 deaths related to skiing (1) and jet skiing (1). All 3 nephrectomies in the nonsports/other group were associated with equestrian activities, and 1 death occurred in this population. The nonsports/other group includes minor sports that are outlined by the American Academy of Pediatrics Committee on Sports Medicine and Fitness. The majority of renal injuries in children associated with kidney loss (21 of 28) occurred as a result of motor vehicle accidents, pedestrians being struck by a vehicle or other object, and falls. There were no kidneys lost in any contact sport. Sledding, skiing and rollerblading resulted in kidney loss. Current recommendations of the American Academy of Pediatrics Committee on Sports Medicine and Fitness prohibiting children with a solitary kidney from participating in contact sports appear to be overly protective and need to be reevaluated. In some instances activities listed as limited contact sports resulted in renal loss, showing that the risk associated with these activities has been underestimated.