Severe Pediatric Trauma Research Articles

CT in pediatric trauma patients.

The decision as to whether to perform a computed tomography (CT) examination in severe pediatric trauma poses a challenge. The therapeutic benefit of computed tomography in injured children is lower compared to adults, while the potential negative effects of ionizing radiation may be higher. Thus, the threshold for CT should be higher. Centers that less frequently treat pediatric cases tend to conduct more whole-body CT examinations than dedicated pediatric trauma centers, indicating a clinical overestimation of injury severity with subsequently unnecessary imaging due to inexperience. On the other hand, a CT scan that is not performed but is actually necessary can also have negative consequences if an injury is detected with a delay. An injured child presents a challenging situation for all involved healthcare providers, and thus requires a structured approach to decision-making.Selective literature review of the benefits and risks of CT in injured children, as well as indications for whole-body and region-specific CT imaging.This article provides an overview of current guidelines, recent insight into radiation protection and the benefits of CT in injured children, and evidence-based decision criteria for choosing the appropriate modality based on the mechanism of injury and the affected body region. · Whole-body CT has less of an influence on treatment decisions and mortality in severely injured children than in adults.. · For radiation protection reasons, the indication should be determined more conservatively in children than in adult trauma patients.. · The indication for CT should ideally be determined separately for each region of the body.. · Ultrasound and MRI are a good alternative for the primary diagnostic workup in many situations.. · Appelhaus S, Schönberg SO, Weis M. CT in pediatric trauma patients. Fortschr Röntgenstr 2024; DOI 10.1055/a-2341-7559.

Mechanical trauma in children and adolescents in Berlin.

Management of severe pediatric trauma remains challenging. Injury patterns vary according to patient age and trauma mechanism. This study analyzes trauma mechanisms in deceased pediatric patients. Fatal pediatric trauma cases aged 0-18 years who underwent forensic autopsy in the Federal State of Berlin, Germany, between 2008 until 2018 were enrolled in this retrospective study. Autopsy protocols were analyzed regarding demographic characteristics, trauma mechanisms, injury patterns, resuscitation measures, survival times as well as place, and cause of death. 71 patients (73% male) were included. Traffic accidents (40%) were the leading cause of trauma, followed by falls from height > 3m (32%), railway accidents (13%), third party violence (11%) and other causes (4%). While children under 14 years of age died mostly due to traumatic brain injury (59%), polytrauma was the leading cause of death in patients > 14 years (55%). Other causes of death were hemorrhage (9%), thoracic trauma (1%) or other (10%). A suicidal background was proven in 24%. In the age group of > 14 years, 40% of all mortalities were suicides. Cardiopulmonary resuscitation was carried out in 39% of all patients. 42% of the patients died at the scene. Children between 0 and 14 years of age died most frequently from traumatic brain injury. In adolescents between 14 and 18 years of age, polytrauma was mostly the cause of death with a high coincidence of suicidal deaths. The frequency of fatal traffic accidents and suicides shows the need to improve accident and suicide prevention for children and adolescents.

Near-infrared spectroscopy monitoring in severe pediatric abusive head trauma.

Abusive head trauma (AHT) is one of the most devastating forms of pediatric traumatic brain injury (TBI). It commonly presents with seizures, which may contribute to poor neurological outcome following trauma. Noninvasive near-infrared spectroscopy (NIRS) neuromonitoring may provide information on cerebral oxygenation and perfusion. In this study, the authors evaluated whether NIRS regional cerebral oxygen saturation (rSO2) values were associated with seizure activity confirmed by electroencephalography (EEG) and whether NIRS neuromonitoring could aid in seizure detection in patients with severe AHT. The authors retrospectively analyzed pediatric patients aged ≤ 18 years who were admitted to a quaternary urban pediatric hospital from 2016 to 2022 with severe AHT, who received NIRS and EEG monitoring during their hospital course. They evaluated clinical presentation and hospital course, including imaging findings, EEG findings, and NIRS rSO2 values. Nineteen patients with severe AHT were monitored with both EEG and NIRS. The median age was 3.4 months, and 14 patients experienced seizures confirmed by EEG. On average, rSO2 values before, during, and after seizure did not differ significantly. However, within individual patients, bilateral regional NIRS rSO2 (bilateral forehead region) was seen to rise in the hour preceding seizure activity and during periods of frequent seizure activity, confirmed by EEG in the bilateral frontal-midline brain regions. To the best of the authors' knowledge, this is the largest study to analyze NIRS and seizures confirmed by EEG in the severe AHT population. The relationship between NIRS values and seizures in this series of pediatric patients with severe AHT suggests that, overall, regional NIRS cannot predict early seizures. However, increased cerebral oxygenation preceding seizure activity and during seizure activity may be detected by regional NIRS in certain patients with local seizure activity. Future studies with larger sample sizes may help elucidate the relationship between seizures and cerebral oxygenation in different regions in severe pediatric AHT.

Pediatric Trauma in The Netherlands: Incidence, Mechanism of Injury and In-Hospital Mortality

BackgroundIn the Netherlands, there are no specialized or certified pediatric trauma centers, especially for severely injured children. National and regional agreements on centralization of pediatric trauma care are scarce. This study aims to describe the incidence, injury mechanism and in-hospital mortality of pediatric trauma in the Netherlands, as a prelude to the further organization of pediatric trauma care.MethodsA retrospective cohort analysis of data from the Dutch National Trauma Registry in 2009–2018, concerning all children (0–16 years) hospitalized due to injury in the Netherlands.ResultsThe annual number of admitted injured children increased from 8666 in 2009 to 13,367 in 2018. Domestic accidents were the most common cause of non-fatal injury (67.9%), especially in children aged 0–5 years (89.2%). Severe injury (injury severity score ≥ 16) accounted for 2.5% and 74% of these patients were treated in level-1 trauma centers. In both deceased and surviving patients with severe injuries, head injuries were the most common (72.1% and 64.3%, respectively). In-hospital mortality after severe injury was 8.2%. Road-traffic accidents (RTAs) were the leading cause of death (46.5%).ConclusionsDomestic accidents are the most common cause of injury, especially in younger children, whereas RTAs are the lead cause of fatal injury. Severe pediatric trauma in the Netherlands is predominantly managed in level-1 trauma centers, where a multidisciplinary team of experts is available. Improving the numbers of severely injured patients primarily brought to level-1 trauma centers may help to further reduce mortality.

Pediatric trauma and emergency surgery: an international cross-sectional survey among WSES members

BackgroundIn contrast to adults, the situation for pediatric trauma care from an international point of view and the global management of severely injured children remain rather unclear. The current study investigates structural management of pediatric trauma in centers of different trauma levels as well as experiences with pediatric trauma management around the world.MethodsA web-survey had been distributed to the global mailing list of the World Society of Emergency Surgery from 10/2021–03/2022, investigating characteristics of respondents and affiliated hospitals, case-load of pediatric trauma patients, capacities and infrastructure for critical care in children, trauma team composition, clinical work-up and individual experiences with pediatric trauma management in response to patients´ age. The collaboration group was subdivided regarding sizes of affiliated hospitals to allow comparisons concerning hospital volumes. Comparable results were conducted to statistical analysis.ResultsA total of 133 participants from 34 countries, i.e. 5 continents responded to the survey. They were most commonly affiliated with larger hospitals (> 500 beds in 72.9%) and with level I or II trauma centers (82.0%), respectively. 74.4% of hospitals offer unrestricted pediatric medical care, but only 63.2% and 42.9% of the participants had sufficient experiences with trauma care in children ≤ 10 and ≤ 5 years of age (p = 0.0014). This situation is aggravated in participants from smaller hospitals (p < 0.01). With regard to hospital size (≤ 500 versus > 500 in-hospital beds), larger hospitals were more likely affiliated with advanced trauma centers, more elaborated pediatric intensive care infrastructure (p < 0.0001), treated children at all ages more frequently (p = 0.0938) and have higher case-loads of severely injured children < 12 years of age (p = 0.0009). Therefore, the majority of larger hospitals reserve either pediatric surgery departments or board-certified pediatric surgeons (p < 0.0001) and in-hospital trauma management is conducted more multi-disciplinarily. However, the majority of respondents does not feel prepared for treatment of severe pediatric trauma and call for special educational and practical training courses (overall: 80.2% and 64.3%, respectively).ConclusionsMulti-professional management of pediatric trauma and individual experiences with severely injured children depend on volumes, level of trauma centers and infrastructure of the hospital. However, respondents from hospitals at all levels of trauma care complain about an alarming lack of knowledge on pediatric trauma management.

Outcomes of basic versus advanced prehospital life support in severe pediatric trauma

ObjectiveThe role of basic life support (BLS) vs. advanced life support (ALS) in pediatric trauma is controversial. Although ALS is widely accepted as the gold standard, previous studies have found no advantage of ALS over BLS care in adult trauma. The objective of this study was to evaluate whether ALS transport confers a survival advantage over BLS among severely injured children. MethodsA retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020 was conducted. All the severely injured children (age < 18 years and injury severity score [ISS] ≥16) were included. Patient survival by mode of transport was analyzed using logistic regression. ResultsOf 3167 patients included in the study, 65.1% were transported by ALS and 34.9% by BLS. Significantly more patients transported by ALS had ISS ≥25 as well as abnormal vital signs at admission. The ALS and BLS cohorts were comparable in age, gender, mechanism of injury, and prehospital time. Children transported by ALS had higher in-hospital mortality (9.2% vs. 0.9%, p < 0.001). Following risk adjustment, patients transported by ALS teams were significantly more likely to die than patients transported by BLS (adjusted OR 2.27, 95% CI 1.05–5.41, p = 0.04). Patients with ISS ≥50 had comparable mortality rates in both groups (45.9% vs. 55.6%, p = 0.837) while patients with GCS <9 transported by ALS had higher mortality (25.9% vs. 11.5%, p = 0.019). Admission to a level II trauma center vs. a level I hospital was also associated with increased mortality (adjusted OR 2.78 (95% CI 1.75–4.55, p < 0.001). ConclusionsAmong severely injured children, prehospital ALS care was not associated with lower mortality rates relative to BLS care. Because of potential confounding by severity in this retrospective analysis, further studies are warranted to validate these results.

Predictive Accuracy of Paediatric Trauma Score, our experience at Children Hospital, Lahore

Aim: To find predictive accuracy of pediatric trauma score (PTS) in terms of mortality in the Children’s hospital and institute of child health Lahore. Study design: Cross sectional study. Setting: Paediatric Surgery department, CH &amp; ICH, Lahore. Duration of study: 1st January 2019 to 30th June 2019. Methods: All patients presented with trauma, aged 1-15 years were included in study. All patients with major burn, associated cardiac injuries (e.g., stab heart), victims who required monitoring and hospitalization less than 24 hours, and those referred to other hospitals were excluded from the study. Initial assessment of all patients was done and paediatric trauma score was evaluated in the emergency room. Patients were managed and 24 hours follow-up was done to predict the mortality. Results: From 290 children, 207(71.38%) were males and 83 (28.6%) were females. Mean age of the children was 7.53 years. The most common mode of trauma was Car accident in children 67(23.1%), followed by Auto rickshaw vs. motorcycle n= 50 (17.24%), and auto rickshaw vs. pedestrian 40(13.79%). Mean Hospital Arrival Time in Minutes was 100.31 minutes. Mean paediatric trauma score amongst all children was 7.22. Overall mortality was reported in 27(9.3%) children. PTS &lt; 8 turned out to be statistically significantly related to mortality (P value &lt; 0.001). Patients with diagnostic test characteristics of PTS &lt; 8 to predict mortality were having sensitivity 91.0%, specificity 56.1%, positive predictive value 38.4%, negative predictive value 95.4% and the diagnostic accuracy of 64.1%. Conclusion: By Paediatric trauma score we can predict about the necessity of critical interventions in patients and also, we can predict percentage of mortality in paediatric trauma patients. However, accuracy of paediatric trauma score seems to be moderate in detecting most severe paediatric trauma cases. Keywords: PTS, mortality, hospital arrival time, morbidity, major burn predictor.

Fibrinogen Early In Severe paediatric Trauma studY (FEISTY junior): protocol for a randomised controlled trial

IntroductionTrauma causes 40% of child deaths in high-income countries, with haemorrhage being a leading contributor to death in this population. There is a growing recognition that fibrinogen and platelets play...

Pediatric ocular trauma with pars plana vitrectomy in Southwest of China: clinical characteristics and outcomes.

To investigate the clinical characteristics and predictive factors of pediatric ocular trauma patients with vitrectomy. Pediatric ocular trauma patients (aged 14y or younger) who received vitrectomy in Southwest Hospital between January 2007 and December 2017 were reviewed retrospectively. Age, gender, mechanism of injury, final visual acuity (VA), and prognostic factors were analyzed. A total of 139 eyes in 139 pediatric patients were included in the study. The mean age was 7.4±3.7 years old and the male-to-female ratio was 5:1. There were 104 (74.8%) open globe injuries and 35 (25.2%) closed globe injuries. The top one traumatic eye injuries were penetrating injuries occur through sharp metal objects (43.9%). After vitrectomy, 116 patients had favorable anatomic outcome at the last follow-up, and 30 eyes (21.6%) achieved VA of 20/200 or better. Following univariate analysis, we found zone III injuries (P=0.021), poor initial VA (P=0.005), endophthalmitis (P=0.024), and recurrent retinal detachment (P<0.001) were poor prognostic factors for pediatric ocular trauma. After Logistic regression analysis, the poor initial VA (odds ratio: 8.276, 95%CI: 1.597-42.897, P=0.012) and recurrent retinal detachment (odds ratio: 6.455, 95%CI: 2.372-17.562, P<0.001) were significantly correlated with unfavorable vision outcome in pediatric ocular trauma. The treatment of vitrectomy for severe ocular trauma results in favorable anatomic outcomes, but VA improvement is not as good as anatomic outcomes. Initial VA and recurrent retinal detachment are the independent prognostic indicators for unfavorable visual outcome of severe pediatric ocular trauma.

Physician and nurses' perception of paediatric trauma care in Israeli emergency departments.

Treatment of paediatric trauma requires specialized infrastructure, medical equipment, medical staff and ancillary support personnel that have been specifically trained for such tasks. To examine the perceptions and attitudes of physicians and nurses in general and paediatric emergency departments (PEDs) on training, confidence, and management of paediatric trauma in order to facilitate the establishment of an optimal model for admitting and treating paediatric trauma patients. Drawing on published literature and a previously conducted qualitative study that explored the provision of medical care to paediatric trauma patients, we conducted an attitude survey. A 26-item paper-based questionnaire was distributed by nurse managers to all staff working within general EDs and PEDs of 22 medical centres across Israel. Of 843 physicians and nurses who completed the survey, 61.1% considered PEDs the most appropriate facility for treating both minor and severe paediatric trauma, 88.5% believed that minor paediatric trauma should be treated in designated paediatric trauma centres, and 53.6% deemed that paediatric emergency medicine specialists are the most suitable primary decision makers in paediatric trauma. PED teams expressed greater professional confidence for treating paediatric trauma and multiple casualty incident patients. Greater professional confidence was positively correlated with paediatric trauma training, greater exposure to paediatric trauma cases, and working in larger medical centres. The results of the current study suggest that PEDs are perceived to be more appropriate for dealing with paediatric trauma. Also, treatment of severe trauma may be more appropriate in centres that admit large numbers of paediatric trauma cases. Emergency medicine teams should undergo training for dealing with paediatric trauma. Such training would develop their skills, increase their confidence, and enhance their emotional abilities to cope with paediatric trauma.

Decreased Human Leukocyte Antigen DR on Circulating Monocytes Expression After Severe Pediatric Trauma: An Exploratory Report.

Major trauma in adults induces immune dysfunction, with diminished expression of human leukocyte antigen-DR on circulating monocytes. No pediatric data are available. This study described the kinetics of human leukocyte antigen-DR on circulating monocytes following major pediatric trauma and relationships between human leukocyte antigen-DR on circulating monocytes and outcomes. Prospective observational study. PICU and trauma unit at a tertiary-care university hospital in South Africa. Children between 1 month and 13 years hospitalized for severe brain trauma or trauma with an Injury Severity Score greater than or equal to 16, from November 2016 to March 2017. None. We included 36 children. Median (interquartile range) age and Injury Severity Score were 7 years (4.9-10.5 yr) and 25 years (22.7-30 yr), respectively. Blood samples (n = 83) for standardized human leukocyte antigen-DR on circulating monocytes measurement were collected at days 1-2, 3-4, and 8-9 after injury (D1, D3, and D8, respectively). On D1, median (interquartile range) human leukocyte antigen-DR on circulating monocytes was markedly reduced relative to normal values (7,031 [5,204-11,201] antibodies per cell). There was a significant increase in human leukocyte antigen-DR on circulating monocytes from D1 to D8. Although all patients with secondary infections (n = 8; 22%) had human leukocyte antigen-DR on circulating monocytes less than 15,000 antibodies per cell at D3, human leukocyte antigen-DR on circulating monocytes levels were not associated with the occurrence of secondary infections (p = 0.22). At D3, human leukocyte antigen-DR on circulating monocytes was significantly higher in patients discharged home (n = 21) by Day 30 after trauma compared with those who died or were still hospitalized (n = 14) (p = 0.02). Pediatric severe trauma induced an early and dramatic decrease in human leukocyte antigen-DR on circulating monocytes expression. This alteration of innate immunity was not associated with the occurrence of secondary infection, possibly due to a lack of statistical power. However, human leukocyte antigen-DR on circulating monocytes at Day 3 is a potential indicator of those at high risk of secondary infection and worse outcomes.

Severe pediatric war trauma: A military-civilian collaboration from retrieval to repatriation.

Modern conflicts take a disproportionate and increasing toll on civilians and children. Since 2013, hundreds of Syrian children have fled to the Israeli border. Severely injured children were triaged for military airborne transport and brought to civilian trauma centers in Israel. After recovery, these patients returned to their homes in Syria.We sought to describe a unique model of a coordinated military-civilian response for the stabilization, transport, and in-hospital management of severe pediatric warzone trauma. Prehospital and in-hospital data of all severe pediatric trauma casualties transported by military helicopters from the Syrian border were extracted. Data were abstracted from the electronic medical records of military and civilian medical centers' trauma registries. Sixteen critically injured children with a median age of 9.5 years (interquartile range [IQR], 6.5-11.5) were transported from the Syrian border to Level I and Level II trauma centers within Israel. All patients were admitted to intensive care units. Eight patients underwent lifesaving procedures during flight, 7 required airway management, and 5 required thoracostomy. The median injury severity score was 35 (IQR, 13-49). Seven laparotomies, 5 craniotomies, 3 orthopedic surgeries, and 1 skin graft surgery were performed. The median intensive care unit and hospital length of stay were 6 days (IQR, 3-16) and 34 days (IQR, 14-46), respectively. Fifteen patients survived to hospital discharge and returned to their families. The findings of this small cohort suggest the benefits of a coordinated military-civilian retrieval of severe pediatric warzone trauma. Therapeutic, Level V.

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.

Efficacy of venous access placement at a pre-hospital scene in severe paediatric trauma patients: a retrospective cohort study

Purpose: Aside from severe traumatic brain injury, uncontrolled bleeding and corresponding haemorrhage shock are the leading causes of traumatic deaths. No established recommendations exist about venous access placement for severely injured, bleeding children at a pre-hospital scene. This study sought to evaluate the association between pre-hospital venous access placement and mortality in a paediatric trauma population by analysing the Japan Trauma Data Bank (JTDB). Methods: This epidemiologic study compared the outcomes of severe traumatic paediatric patients with or without venous access placement at a pre-hospital scene. Data were obtained from JTDB from 2004 to 2015. Results: Of 4,109 patients who met our inclusion criteria, 144 patients received venous access placement and 3,965 patients did not. The probability of survival was lower in the venous access group than in the no access group (0.90 [0.67–0.97] vs. 0.97 [0.90–0.99], p < 0.01). After multivariable logistic analysis, venous access placement did not improve survival to hospital discharge (odds ratio = 1.40, confidence interval = 0.32–6.15, p = 0.653). Conclusions: The probability of survival was lower in the venous access group than in the no access group. Survival outcome at discharge was not affected by venous access placement at a pre-hospital scene.

Epidemiology of severe paediatric trauma following winter sport accidents.

This study describes the epidemiology of severe injuries related to winter sports (skiing, snowboarding and sledding) in children and assesses potential preventive actions. A single-centre retrospective study performed at Pediatric or Adult Intensive Care Unit in the French Alps. All patients less than 15years old, admitted to the Intensive Care Unit following a skiing, snowboarding or sledding accident from 2011 to 2018, were included. We included 186 patients (mean age 10.6years and 68% were male); of which 136 (73%), 21 (11%) and 29 (16%) had skiing, snowboarding and sledding accidents, respectively. The average ISS (injury severity score) was 16. The major lesions were head (n=94 patients, 51%) and intra-abdominal (n=56 patients, 30%) injuries. Compared to skiing/snowboarding, sledding accidents affected younger children (7 vs 11years, P<.001); most of whom did not wear a helmet (89% vs 8%, P<.001). Severity scores were statistically different amongst winter sports (ISS=16 (IQR 9-24) for skiing, 9 (IQR 4-16) for snowboarding and 16 (IQR 13-20) for sledding accident, P=.02). Winter sports can cause severe trauma in children. Sledding accidents affect younger children that may benefit from wearing protective equipment.

Outcomes After Prehospital Endotracheal Intubation in Suburban/Rural Pediatric Trauma

BackgroundTrauma is the leading cause of death in pediatric patients over 1 y of age. Controversy exists regarding prehospital airway management for these patients, with some studies suggesting that endotracheal intubation in the field or at a referring hospital is associated with increased mortality and complication rate. These studies were largely performed at urban centers, and it is unclear whether the results apply to suburban/rural networks with longer transport times and more stops at referring hospitals. The purpose of this study is to evaluate differential outcomes in pediatric trauma patients who underwent endotracheal intubation at the scene of injury, referring hospital, or pediatric trauma center in a predominantly rural/suburban setting. Materials and methodsA retrospective review was performed evaluating trauma patients age 18 y or younger at a single institution over 10 y (2004-2014). Patients were selected who underwent endotracheal intubation and were classified based on location of intubation (scene, referring hospital, or trauma center). Fischer's exact test and t-tests were performed for comparison. Univariate and multivariate regression analyses were performed. Results288 patients were identified. 155 (53.8%) were intubated at the scene of injury, 55 (19.1%) at a referring hospital, and 72 (25%) at the trauma center. Overall mortality was 21.9%, which was highest in the scene intubation group (29.7%) compared with the referring hospital (20%) and trauma center (5.6%) groups (P < 0.01). Patients intubated at the scene had higher Injury Severity Scores and lower Glasgow Coma Scale scores (P < 0.01). Duration of intubation was lowest in the trauma center group (P < 0.01). Complication rate was highest in the referring hospital group (P < 0.05). Multivariate analysis revealed that age, injury severity, and neurologic status were the key drivers of mortality rather than location of intubation. ConclusionsMortality and duration of intubation were lowest in trauma patients intubated at a pediatric trauma center. However, location of intubation was not a significant independent predictor of mortality or complications on multivariate analysis, suggesting that age, injury severity, and neurologic status are the main indicators of prognosis in severe pediatric trauma.

241EMF Identifying Impacts of Undertriage Among Severe Pediatric Trauma Patients

The objective of this study was to detect factors associated with undertriage of pediatric trauma and establish the influence of undertriage on inter-facility transfer and mortality. This is a retrospective cohort study of all-payer administrative claims data of all emergency department (ED) and inpatient visits in a large, southeastern state between 2010 – 2015. Pediatric (<15 years) trauma patients were identified by ED diagnostic codes and restricted to severe injury using validated injury severity score (≥ 15). Undertriage was defined as initial care in a nontrauma (Level 3 or higher) center (pediatric or adult), as assigned by the state. Univariable and multivariable regression were used to identify risk factors for undertriage and the impact of undertriage on mortality and length of stay. Covariates included age, sex, race, ethnicity, expected primary payer, rurality, injury severity (ISS 15-25 or >25), admission timing (weekend versus weekday), and quartile of median household income (by zip code). Overall, 4,382 pediatric severe trauma subjects were included and 74.4% (n=3,260) were initially managed outside of an ED in a Level I or Level II trauma center. These subjects were more likely to be white, privately or non-insured, and reside in non-metro zip codes. Rural residence was the greatest risk factor for presenting at a nontrauma center (aOR: 4.10 [95% CI 2.62 to 6.43]). Eleven percent (n=482) of the subjects died during the initial hospital encounter, and initial assessment at a nontrauma center compared to trauma center was not associated with mortality (aOR: 0.81 [95% CI 0.60 to 1.09]). Length of stay, including ED and hospital stay, did not differ between subjects presenting to EDs at trauma or nontrauma centers (adjusted β: 1.05 [95% CI 0.96 to 1.15]). Additionally, 5.0% of subjects were transferred, but inter-hospital transfer was not associated with undertriage (aOR: 0.86 [95% CI 0.62 to 1.19]). Initial presentation at EDs that are not pediatric or adult trauma centers is common among severe pediatric trauma patients. Mortality, length of stay, and transfer patterns do not differ between trauma patients initially presenting to trauma versus nontrauma centers, even after adjusting for patient and facility characteristics. The high proportion of pediatric trauma patients seen outside of trauma centers is in line with previous reports in other state trauma systems. Absence of an observed impact of undertriage on mortality in this study may be due to differences in rural-urban disparities, a more mature trauma system and transfer protocols, or increased capability to manage trauma in nontrauma centers within the state. Future work will focus on incorporating emergency medical services availability and restricting the population to a more specific (ISS>25) definition of severe trauma.

&lt;p&gt;The UK Paediatric Ocular Trauma Study 3 (POTS3): clinical features and initial management of injuries&lt;/p&gt;

PurposeWorldwide, as many as 6 million children annually sustain ocular trauma, with up to a quarter of a million children requiring hospitalization. Management of pediatric ocular trauma differs from that in adults, both in terms of initial assessment and acute intervention, with significant variation in practice between different centers. Patterns of healing and long-term outcomes are also very different for children compared to adults. In order to develop effective protocols for management, it is first necessary to understand current trends in presentation and treatment.MethodsWe conducted a prospective, observational study of pediatric ocular trauma presenting to UK-based ophthalmologists over a one-year period; reporting cards were distributed by the British Ophthalmic Surveillance Unit, and clinicians were asked to report cases of acute orbital and ocular trauma in children aged 16 years or less requiring inpatient or day-case admission. A validated, standardized questionnaire was sent to reporting ophthalmologists to collect data on clinical features and initial management of injury.ResultsEighty-six episodes of pediatric ocular trauma were reported. Trauma involving the globe was reported in 66/86 patients (76.7%), of which 40/66 (60.1%) were open-globe. Trauma to the anterior segment was reported in 57/86 (66.3%), and posterior segment in 23/86 patients (26.7%). Twenty-five of 86 (29.1%) patients sustained severe trauma defined as having best-corrected visual acuity worse than 6/60 Snellen (incidence 0.19 per 100,000 population).ConclusionsThere has been no improvement in the incidence or severity of pediatric ocular injury rates over the past 25 years. Eye-care providers must be able to provide the necessary services for assessment and management of severe pediatric ocular trauma in the emergency setting.

Predictors for Pediatric Blunt Cerebrovascular Injury (BCVI): An International Multicenter Analysis.

Practice guidelines for adult BCVI patients have been implemented recently, but data for this devastating injury pattern in children are still limited. An international multicenter analysis was performed to characterize BCVI in the pediatric population. The TraumaRegister DGU®, a prospectively maintained database, was analyzed (01/2002-12/2015). Pediatric patients (0-17years) with major injuries [Injury Severity Score (ISS) ≥ 9 points] were included. BCVI was divided into carotid artery injury and vertebral artery injury (VAI). Data of demographics, injury, imaging, therapy, and outcome characteristics were analyzed with SPSS (Version 25, IBM Inc., Armonk, NY). The study cohort included 8128 pediatric trauma patients. We identified 48 BCVIs in 42 children, resulting in an overall prevalence of 0.5%. Carotid injuries were diagnosed more frequently (n = 30; 0.4%) when compared to VAIs (n = 12; 0.1%). The coincidence of head (p = 0.028), facial (p ≤ 0.001), chest (p ≤ 0.001), and spinal injuries (p ≤ 0.001) was higher in BCVI patients. The risk for thromboembolic complications (8.3% vs. 1%, p = 0.026) and in-hospital mortality (38.1% vs. 7.7%, p ≤ 0.001) was excessive in children with BCVI. We identified various predictors for pediatric BCVI and quantified the cumulative impact of these risk factors. BCVI is more uncommon in pediatric than in adult trauma patients. Due to the considerable relevance of this injury for both children and adults, special attention should be paid to this entity and associated complications in the early treatment phase after severe pediatric trauma, especially in high-risk children.