Life-saving interventions in pediatric trauma: A National Trauma Data Bank experience

Pediatric Resuscitative Thoracotomy in Infants, Children, and Early Adolescents: A Scoping Review

INTRODUCTION

Recent publications sought to define the role of resuscitative thoracotomy (RT) in the pediatric population; however, few studies guide its use in young children and infants. This review characterizes the presentation and outcomes of patients ≤15 y old undergoing RT.

METHODS

A scoping review querying publications in PubMed, Embase, and Scopus prior to March 2024 was conducted using Covidence software. Eligible articles reported outcomes of patients aged ≤15 y old receiving RT for traumatic injury. The exclusion criteria included non-English, data in aggregate with patients >15 y old or lack of outcomes. Eligible articles underwent data extraction for mechanism of injury, hospital presentation, procedure details, and survival.

RESULTS

The search imported 1550 articles, 294 underwent full-text review, and 26 were included. Notably, 85 articles were excluded for failing to separate pediatric and adult outcomes. Reviewed literature reported on 459 pediatric patients, of which 81 survived (17.6%). Age reporting varied as follows: 10 articles reported the exact age, 5 reported age buckets, and 11 reported an age range only. Of the survivors with known ages, three were <1 y old, seven were 1-4 y old, ten were 5-9 y old, and 39 were 10-15 y old.

CONCLUSIONS

The utility and indications for pediatric RT are understudied in the youngest children. Current literature is limited by inconsistent reporting and poor data granularity. Establishing universal reporting guidelines for pediatric RT will help build complete, uniform databases. A preliminary reporting checklist is proposed to improve data sharing in pediatric RT literature, serving as a first step toward developing evidence-based protocols for young children and infants undergoing RT.

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

INTRODUCTION

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.

MATERIALS AND METHODS

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.

RESULTS

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.

DISCUSSION

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.

Characteristics of Pediatric Emergency and Risk Factors for Life-saving Interventions

Pediatric emergency patients are vulnerable population and require special care or interventions. Nevertheless, there is limited data on the prevalence and risk factors for life-saving interventions. This study is a retrospective analytical study. The inclusion criteria were children aged 15 years or under who were triaged as level 1 or 2 and treated at the resuscitation room. Factors associated with LSI were executed by logistic regression analysis. During the study period, there were 22 759 ER visits by 14 066 pediatric patients. Of those, 346 patients (2.46%) met the study criteria. Triage level 1 accounted for 16.18% (56 patients) with 29 patients (8.38%) with LSI. Trauma was an independent factor for LSI with adjusted odds ratio (95% CI) of 4.37 (1.49, 12.76). In conclusion, approximately 8.38% of these patients required LSI. Trauma cause was an independent predictor for LSI.

Nationwide analysis of resuscitative thoracotomy in pediatric trauma: Time to differentiate from adult guidelines?

BACKGROUND

Emergency department thoracotomy (EDT) for pediatric patients is uncommon, and practice patterns have not been evaluated. We examined the indications and outcomes for EDT by trauma center designation using a nationwide database.

METHODS

Patients 16 years or younger who underwent EDT within 30 minutes of arrival from 2013 to 2016 were identified in the American College of Surgeons National Trauma Data Bank. Patient demographic information, indications for EDT, and outcomes were analyzed. Outcomes were compared between centers with and without pediatric trauma center designation.

RESULTS

A total of 114 patients were identified for analysis with a mean ± SD age of 10.3 ± 4.7 years. Patients were predominantly male (69%) with a median Injury Severity Score of 26 (interquartile range, 18-42). Penetrating trauma occurred in 56%. Overall, mortality was 90% and was similar in penetrating and blunt trauma (88% vs. 94%; p = 0.34). There were no survivors among the 53 patients (46%) who arrived with no signs of life. Among the 11 patients (10%) who survived, median length of stay was 26 days (interquartile range, 6-28 days). Overall, 8% of EDT was performed at free-standing pediatric trauma centers, 45% at adult centers, and 47% at combined trauma centers. Mortality rates and indications were similar among trauma centers regardless of designation status.

CONCLUSION

In a national population-based data set, the mortality after pediatric EDT is high, and many of these procedures are performed at nonpediatric trauma centers. Regardless of injury mechanism, EDT is not appropriate in children without signs of life on arrival. Pediatric guidelines are needed to increase awareness of the poor outcomes and limited indications for EDT.

LEVEL OF EVIDENCE

Therapeutic, level IV.

Pediatric firearm mortality in the United States, 2010 to 2016: A National Trauma Data Bank analysis

BACKGROUND

Pediatric firearm injury is a leading cause of death for U.S. children. We sought to further characterize children who die from these injuries using a validated national database.

METHODS

The National Trauma Data Bank 2010 to 2016 was queried for patients aged 0 to 19 years old. International Classification of Diseases external cause of injury codes were used to classify patients by intent. Differences between groups were analyzed using χ or Mann-Whitney U tests. Patterns over time were analyzed using nonparametric tests for trend. Multivariable logistic regression was used to investigate associations between the above factors and mortality.

RESULTS

There were a total of 45,288 children with firearm injuries, 12.0% (n = 5,412) of whom died. Those who died were younger and more often white than survivors. Mortality was associated with increased injury severity, shock on presentation, and polytrauma (p < 0.001 for all). There was an increasing trend in the proportion of self-inflicted injuries over the study period (p < 0.001), and mortality from these self-inflicted injuries increased concordantly (35.3% in 2010 to 47.8% in 2016, p = 0.001). Location of severe injuries had significant different mortality rates, ranging from 51.3% of head injuries to 3.9% in the extremities. In the multivariable model, treatment at a pediatric trauma center was protective against mortality, with odds ratios of 2.10 (confidence interval, 1.64-2.68) and 1.80 (confidence interval, 1.39-2.32) for death at adult and dual-designated trauma centers, respectively. This finding was confirmed in age-stratified cohorts.

CONCLUSION

Proportions of self-inflicted pediatric firearm injury in the National Trauma Data Bank increased from 2010 to 2016, as did mortality from self-inflicted injury. Because mortality is highest in this subpopulation, prevention and treatment efforts should be prioritized in this group of firearm-injured children.

LEVEL OF EVIDENCE

Epidemiological study, level V.