Traumatic deaths in children: the importance of prevention

Fatal traffic injuries among children and adolescents in three cities (capital Budapest, Vilnius, and Tallinn)

Motor vehicle accidental injuries are a frequent cause of death among young children and adolescents. The goal of this study was to compare patterns of injury between three capitals (Budapest, Vilnius, and Tallinn). Information on 190 fatal traffic accidents (69 pedestrians, 14 bicyclists, and 107 motor vehicle occupants) between 2002 and 2006 was collected from databases of medico-legal autopsies. The role of victims in accidents, the location of injuries, cause of death, survival period, and blood alcohol levels were evaluated. One-hundred and forty-one (74%) victims had a passive role in traffic as pedestrians, passengers in cars, or public transport. In victims who died at the scene, the rate of head injury was higher than in cases who received medical treatment (odds ratio = 2.58, CI = 1.2-5.55, p = 0.0127). These results underline the importance of postmortem studies to examine the pathomechanism of fatal traffic accidental injuries and to provide information for the prevention of road traffic accidents against children and adolescents.

Mortalities among children and adolescents in manipal, southern India

OBJECTIVE

To describe the epidemiology and trends of traumatic deaths among children and adolescents in Manipal, Southern India.

METHODS

Analysis of all trauma deaths in children and adolescents aged between 1 and 19 years, autopsied between January 1994 and December 2005. The study is based on autopsy records, information furnished by the police, and chemical analysis report.

RESULTS

There has been a substantial decline in the incidence of traumatic deaths among children and adolescents during 1994 to 2005. Road traffic injuries were responsible for maximum mortalities (38.4%), followed by those because of burns (24.9%) and poisoning (15.9%). Males comprised 59.6% of cases. Male-to-female ratio was 1.5:1. Males predominantly died of traffic injuries (45.2%), whereas females as a result of burns (37.4%). There was more than two-fold increase in injury-related mortalities from childhood to adolescence (1:2.3).

CONCLUSION

Among children and adolescents, traffic injuries and burns are responsible for maximum injury-related mortalities in males and females, respectively. More injury reducing measures are required for effective reduction in traumatic deaths.

Accidental childhood fatalities in Manipal, India

Children in the first decade of life are extremely vulnerable to accidents. Seventy-five cases of accidental deaths in children aged less than ten years were identified in a retrospective review of medicolegal autopsies during 1993–2006 in Manipal, India. Boys were more likely to suffer accidental death that girls (male–female ratio 2.3:1). Road traffic accidents accounted for the majority of the deaths (56%), followed by burns (21.4%).

[Injury pattern and clinical course of children with multiple injuries in comparison to adults, Ab 11-year analysis at a clinic of maximum utilization]

Due to the small number of polytraumatized children treated in single clinics, only a few studies are available that compare multiply injured children and adults. However, the differences between the two groups with respect to type of injury, injury patterns and pathophysiology may have some crucial effect on the clinical course and are therefore essential for the treatment regime. In this study data about the epidemiology, the preclinical treatment, the clinical course and the complication rates of polytraumatized children and adults were analysed. The aim of this study was to point out the main differences between the two collectives and to compare the results with the current literature. Traffic accidents were the leading cause for trauma (children 77.8%, adults 62.6%). Children more often were transported by helicopter than adults. In both age groups head injuries and fractures of the extremities were most frequent. Adults had a prolonged ventilation time as well as an increased stay in ICU and a regular ward.

Paediatric trauma at an adult trauma centre

BACKGROUND

Trauma in children remains the commonest cause of mortality. The majority of injured children who reach hospital survive, indicating that additional more sensitive outcome measures should be utilized to evaluate paediatric trauma care, including morbidity and missed injury rates. Limited contemporary data have been presented reviewing the care of injured children at an adult trauma centre (ATC).

METHODS

A review was undertaken of injured children who warranted activation of the trauma team, treated within the emergency department of an ATC (Royal North Shore Hospital) situated in the Lower North Shore area of Sydney. Data were collected prospectively and patients followed through to death or discharge from the ATC or another institution to which they had been transferred.

RESULTS

A total of 93 children were admitted to the ATC between January 1999 and April 2002. Mean age was 9 years 3 months (range 5 weeks-15 years 9 months) and 70% were male. The median injury severity score was 15 (range 1-75) and there were three deaths. Forty-two children were transferred to a paediatric trauma centre (PTC), including three children who had been transferred to the ATC from another hospital. There was one missed injury and one iatrogenic urethral injury.

CONCLUSIONS

The majority of children with trauma were treated safely and appropriately at the ATC. The missed injury rate was < 1% and there were no adverse long-term sequelae of initial treatment. Three secondary transfers could have been avoided by more appropriate coordination of the initial referral to a PTC.

Medicolegal Childhood Deaths in Adana, Turkey

The objective of this study is to determine the characteristics of and changes in the medicolegal childhood deaths that occurred in the provincial center of Adana, and to contribute to the establishment of a database for the development of national and international policies. The study is a retrospective research examining the 1,110 cases in the age group 0 to 18, which were specified as medicolegal deaths in the provincial center of Adana-Turkey between the years 2000-2004. The cases were examined according to age, sex, causes of deaths, the origins and scenes of occurrence. Among all the deaths, 523 cases (47.2%) were seen in the age group of 0-6 years. Accidents account for 900 cases (81.1%), and blunt traumas (594 cases) represent the most common cause of deaths. The share of traffic accidents in total blunt traumas was found to be 441 cases (74.2%). And 270 (24.3%) of all medicolegal deaths occurred as a result of household accidents. The present study has also indicated that the home and surroundings represent the highest-risk areas. As a conclusion, setting up childhood injury prevention committees and providing training programs for parents will be effective for the prevention of childhood injuries and deaths.

Children at play: the death and injury pattern in New South Wales, Australia, July 1990-June 1994

OBJECTIVES

To describe and to understand the pattern of play-related deaths and injury (excluding organized sports) among children in New South Wales (NSW), Australia.

METHODOLOGY

This study utilized a state-wide prospective surveillance data collection of paediatric traumatic deaths and injuries at the Royal Alexandra Hospital for Children. Deaths and injury cases were selected from the NSW Trauma Death Registry and Childsafe NSW database. Information including basic demographics, the surrounding circumstances of death and injury incidents, and the required treatment was collected.

RESULTS

There were 30 play-related deaths and 92 drownings over the 4-year period. The male to female ratio was about 2:1. Excluding drowning, which has been reported elsewhere, and sports, the leading causes of play-related deaths were burns (eight) and asphyxiation (eight). An average of 6444 presentations to the emergency departments per year were recorded with sex ratio and age distribution pattern similar to the deaths. The home was the most common place (55.5%) of play-related injury, specifically the living and sleeping area. Falls, both under and above 1 metre, were the most common causes of injury (50.9%). The leading mechanism was cuts and lacerations (21.2%). Nearly one-third (32.7%) of all injuries were to the head, with face, cheek, forehead and scalp as the most common injured body part. Significant associations between place of injury, injured body parts and age were observed.

CONCLUSIONS

Play-related injury is common among children, and in some cases causes severe injury and death. To tackle the problem of play-related deaths and injuries, a holistic approach is suggested. This includes the provision of a safe environment, supervision by parents, education of children and detailed data collection.

Facial burns in children: a series analysis with implications for resuscitation and forensic odontology

This study comprises a continuous (1981-1995) unselected series of all children who died from thermal injuries in the State of Queensland, Australia. One hundred and six children, so identified, died from incineration (35 per cent), respiratory burns with smoke or carbon monoxide inhalation (33 per cent), body surface area burns comprising greater than 60 per cent (9 per cent) and electrocution (20 per cent). The burn fatality rate was 0.98 per hundred thousand children (0-14 years) per year, with no secular trend and, specifically, no reduction in the annual rate of such fatalities. Eighty-two children (49 males) had concomitant facial injuries, both thermal and nonthermal; of whom 55 per cent were under the age of five years. Sixty (73 per cent) child burn victims died in house fires. Forensic odontology is important in confirming the age of such victims in single incinerations but is of limited value when larger numbers of children are incinerated, because of the relative lack of dental restorations in the infant and pre-school age group. Of the 82 children with facial and airway injuries, 12 per cent had only mild or superficial facial damage and only seven (8 per cent) were alive or resuscitable at the time of rescue from the conflagration or burning injury. child deaths from burns contributed an annual loss rate of 506 years of potential life lost (YPLL) in a population of 3 million of whom 21.5 per cent were children under the age of 15 years. Airway management and resuscitation, in the context of managing surviving burn victims of any age with facial injuries, pose special difficulties. Inhalational burns (smoke and the gases of conflagration) result in a mortality greater than 60 per cent. Although 81 per cent of children showed evidence of airway obstruction, analysis of current data indicates that a maximum of 8 per cent could have survived with airway maintenance and protection. Inhalational burns (to both upper and lower airways) grossly reduce survivability. Primary prevention would seem vital and thus remains a major challenge to reduce the incidence of such deaths. Some strategies include advocacy to promote the compulsory installation of smoke alarms, family drills to practise escape and the teaching of 'first aid for all'

Studies of avoidable factors influencing death: a call for explicit criteria

OBJECTIVE

To analyse studies evaluating cases of potentially "avoidable" death.

DESIGN

The definitions, sources of information, and methods were reviewed with a structured protocol. The different types of avoidable factors,--that is, deficiencies in medical care that may have contributed to death--were categorised. The presence of explicit classifications and standards was examined. basic criteria for quality of the studies were defined and the numbers of studies fulfilling these criteria were assessed.

SETTING AND PARTICIPANTS

65 studies, published during 1988-93 in peer reviewed medical journal for which the title, or abstract, or both indicated that they had analysed potentially avoidable factors influencing death. Studies analysing aggregated data only, were not included.

RESULTS

Only one third of the studies fulfilled basic quality criteria,--namely, that the avoidable factors examined should be defined and the sources of information and people responsible for the judgements presented. The definitions used comprised two levels, one stating that there had been errors in management (process) and the other that the errors may have contributed to the deaths (outcome). Only 15% of the studies explicitly defined what type of factors they had looked for and 8% referred to specified standards of care.

CONCLUSIONS

Studies of avoidable factors influencing death may have considerable potential as part of a system of improving medical care and reducing avoidable mortality. At present, however, the results from different studies are not comparable, due to differences in materials and methods. There is a need to improve the quality of the studies and to define standardised explicit definitions and classifications.

Towards a research strategy to support public health programs for behaviour change

Major public health programs have had mixed results in improving health behaviours. In part, the failure to modify some key health behaviours is attributable to a lack of appropriate research on which to base behaviour-change programs. The research published by the Australian Journal of Public Health (now the Australian and New Zealand Journal of Public Health), as representative of Australian research, was analysed. The analysis indicated shortcomings in existing research as a basis for practitioners to build effective programs. While the Journal publishes a substantial amount of health-behaviour research, few studies used a randomised trial to assess the effects of interventions. Little research was designed to help practitioners to: identify the types of strategies that would reliably result in behaviour change; identify strategies to work with hard-to-reach groups like women from Aboriginal and non-English-speaking backgrounds; assess the costs and cost-effectiveness of different strategies; disseminate effective strategies at a state or national level. If improvements in public health are to occur, there is a need to develop and implement a strategy to ensure that research more effectively meets the needs of public health practitioners.

Biosocial variables and auditory acuity as risk factors for non-fatal childhood injuries in Greece

OBJECTIVES

To examine whether biosocial variables and auditory acuity are risk factors for injuries among children.

SETTING

Children with injuries who presented at the emergency clinics of one of the two university hospitals for children in Athens, Greece between December 1993 and April 1994.

METHODS

144 children aged 5-14 years, residents of Athens, were brought to the emergency clinics for a moderate to severe injury. For each of these children one hospital control, matched for age and sex, and one classmate control similarly matched were identified. A standard interview form was completed for all 432 children and acouometric and tympanometric examinations were performed in each of them. Analysis was done through conditional logistic regression.

RESULTS

The likelihood of an accident was higher in children of younger fathers (odds ratio (OR) = 0.7, p = 0.04), children of mothers with non-professional jobs (OR = 1.9, p = 0.03) as well as in children of higher birth order (OR = 1.7, p = 0.01), in those with predominantly other than parental daily supervision (OR = 2.6, p = 0.001), and those with a history of previous accident (OR = 1.3, p = 0.002). Somatometric factors, school performance, use of corrective eyeglasses and subnormal auditory acuity were not found to be risk factors, but auditory imbalance and abnormal tympanograms were positively related to the risk of childhood injury (OR = 2.6, p = 0.02; and OR = 2.3, p = 0.08 respectively).

CONCLUSIONS

the findings of this study underline the importance of attentive supervision and safety training of children living in modern cities; they also suggest that children with auditory imbalance and history of an accident are at higher injury risk and they should be targeted with specific intervention programs.

Fatal childhood injury patterns in an urban setting

STUDY OBJECTIVE

To describe fatal childhood injury patterns in an urban county and evaluate the use of the emergency medical services system.

DESIGN

Retrospective chart review of medical examiner files, prehospital and hospital records, and police and fire personnel reports.

SETTING

Milwaukee County, Wisconsin, an urban county with a population of approximately 1 million.

PARTICIPANTS

All children 15 years old or younger who sustained a fatal injury in 1989 or 1990 (70).

RESULTS

House fires were the leading cause of death by injury (34%), followed by firearms (19%), and drowning (11%). Motor vehicle occupant deaths occurred less frequently (7%). One-third of deaths were homicides (48% firearms and 30% assault). Twenty-four percent of deaths were pronounced at the scene, 12% were dead-on-arrival (no emergency department resuscitative efforts), and 37% were dead-on arrival ED resuscitations. Only 27% of victims survived to become inpatients (84% died within 72 hours). Mean scene time (16.1 +/- 7.9 minutes), transport time (9.5 +/- 5.1 minutes), and success rates for prehospital peripheral IV insertion (72%), endotracheal intubation (91%), and intraosseous line (86%) were not significantly different among those who were dead-on-arrival, dead-on-arrival failed resuscitations, or eventual inpatients.

CONCLUSION

Fatal childhood injury patterns in this urban setting differed from reported national injury patterns. This study found a higher percentage of deaths from fire, gunshot wounds, and homicides but a lower percentage of motor vehicle-related deaths. Prevention strategies need to address the injury patterns of a particular community. Only a small percentage of victims survived to receive inpatient care following their injuries, suggesting that primary prevention of injury may be the most effective intervention.

Drowning and near-drowning

The incidence, epidemiology, and pathophysiology of drowning and near-drowning are presented. Particular attention is paid to the neurologic and pulmonary pathophysiology indicators for monitoring and laboratory tests. Special attention to transportation of patients is given, and treatment in the field, emergency department, and pediatric intensive care unit is delineated.

Impact of pedestrian injury on inner city trauma services

This report describes the epidemiology of pedestrian injury in four inner metropolitan local government areas of Sydney. These data were obtained from the Roads and Traffic Authority of New South Wales. The spectrum of injury and clinical outcome was defined in patients with an Injury Severity Score (ISS) > 15 admitted from the study area, during a 1 year period, to the four inner metropolitan teaching hospitals. The incidence of pedestrian death was 3.3 times the state average of 32/10(6)/year. An average of 235 pedestrians, injured in the study area, were hospitalized each year during the period 1987-89. On average 24 pedestrians died each year, seven at the scene and 17 in hospital. Fifty patients (ISS > 15) were admitted to the four teaching hospitals during a 1 year period 1990-91. Forty-five were adults and five children. Multiplicity of injury was seen in 68% of patients. The pelvis and lower extremities were involved in 70%, the head in 66% and chest in 42%. The hospital mortality rate was 30% with five patients dying on the first day from blood loss and nine dying during subsequent days from head injury. This study has important implications for trauma service development. Successful clinical management of the severely injured pedestrian requires close co-operation between pre-hospital and hospital care providers. An integrated hospital trauma team response is mandatory to ensure appropriate management of what is often a shocked, hypoxic, head-injured patient.

Pediatric spinal injury: review of 61 deaths

Injury to the spinal column and spinal cord occurs relatively infrequently in the pediatric population. The authors present a unique review of 61 pediatric deaths associated with spinal injury. This group represented 28% of the total pediatric spine-injured population and 45% of the total pediatric spinal cord-injured group studied. The ratio of pediatric to adult spinal injury mortality was 2.5:1. Of the 61 children, 54 (89%) died at the accident scene. Thirty patients underwent a complete autopsy, 19 of whom had an Abbreviated Injury Scale Grade 6 injury (maximum score, untreatable). Spinal cord injury was found to be the cause of death in only eight children and was associated with injury to the high cervical cord and cardiorespiratory arrest. These children typically sustained severe multiple trauma. In this population, there appears to be little room for improved outcome through changes in treatment strategy.

Preventive health behaviours among parents of infants aged four months

Six preventive health behaviours have been frequently identified as having the potential to reduce mortality and morbidity during infancy: breast-feeding until the age of six months; no solid food until after four months of age; immunisation against whooping cough, diphtheria, poliomyelitis and tetanus; the use of a baby capsule to restrain the infant when travelling in a motor vehicle; regular attendance at a health care provider for preventive health checks; and no maternal smoking. This study surveyed 191 primiparous women four months after the birth of their babies to explore the proportion of parents who perform the recommended preventive health behaviours and the association among the behaviours. Thirty-nine per cent of the women reported that they were no longer breast-feeding by the time their infant was four months old; 35 per cent had introduced solids before 16 weeks of age; 35 per cent did not always use a baby capsule when travelling with their baby in their car, 25 per cent did not regularly attend the early childhood health centres and 22 per cent smoked. Forty-eight per cent of the sample were performing four or fewer of the six preventive health behaviours and 21 per cent were performing three or fewer. The relationship between performing each preventive health behaviour and a range of demographic variables was investigated. A logistic regression indicated that performing three or fewer of the health behaviours was associated with lower levels of education, having public health insurance and being born in a country other than Australia.

The cost and availability of devices for preventing childhood injuries

Accidental injury is the major cause of death among Australian children. Many childhood injuries are preventable through the use of safety devices such as those recommended by the Child Accident Prevention Foundation of Australia (CAPFA). It has been suggested that poor availability and the high cost of obtaining and installing safety devices may contribute to their low rates of use among families with young children. This paper assesses the availability and cost of recommended safety devices in a medium sized city in Australia. Of the 17 devices recommended by the CAPFA only 10 were readily available in Newcastle. The cost of purchasing and installing all the devices recommended by CAPFA amounted to $1516, or 21.4% of the annual disposable income, after the purchase of necessities, of families with children and 75.5% of the annual disposable income, after purchase of necessities, of single parents. It is argued that the cost of safety devices may be prohibitively expensive, particularly for those most at risk of suffering from injury.

Resource allocation in contemporary paediatrics: the case against high technology

High technology has introduced a new dimension to medical treatment. There are inevitable social costs as well as benefits, and the allocation of resources to high technology, as opposed to other areas of health care, is a contentious issue. The current balance in health service funding between high technology and low technology is not appropriate. It is driven by the technological imperative and only offers solutions to a limited number of problems. There is a scarcity of health resources left to develop intersectoral responses and provide adequate funding for research into person-intensive interventions suitable for many problems. Arguments against allocating too many resources to high technology in paediatrics are examined in this paper.

Child drownings: a changing pattern

Paediatric drownings in New South Wales during the years 1987-1990 are reviewed to document the current pattern. Over these three years we have registered 250 paediatric deaths by physical injury. Sixty-one (24%) of these deaths were by drowning. Twenty-nine of the 61 drownings (47%) occurred in domestic pools; 25 of these were in unfenced or inadequately fenced pools. Of the remaining four cases, one was associated with a chair being used to gain access and the other three remain unexplained. Thirty-three of the 61 drownings occurred in country areas; of these 10 were in pools, eight in rivers or creeks, six in boating accidents, four in the surf and three in dams. A changing trend identified by this study is the increasing percentage of drownings (44%) occurring in nominally "fenced" pools in which the fencing was not functioning because the gate was open or the fencing was in disrepair. Legislation must be supported by public education and council inspection if the full benefit of isolation fencing is to be realised. With respect to all drownings there is a continuing need for education about the dangers that bodies of water, even in the bath or a bucket, pose to young children, and the need for parents to strive for optimal supervision.

The physician's role in injury prevention: beyond the U.S. Preventive Services Task Force report

Injuries and their prevention have received little attention by the medical community, despite the fact that injuries are the leading cause of premature death. However, much can be done to reduce the number and severity of injuries, and the practicing physician has an important role to play in this process. This report outlines the U.S. Preventive Services Task Force report recommendations for prevention strategies to reduce injuries and then seeks to define a broader role for the physician in prevention injuries that extends beyond the confines of office-based practice. While screening and counseling have proven effectiveness in certain situations, interventions that are passive or automatic in action, such as air bags, have proven to be more effective long-term solutions to reduce both the number and the severity of injuries. The author outlines and provides examples of seven areas where physicians can have a major impact either directly or through implementing effective injury-control strategies. These are: treatment, education, screening, hazard identification, research, advocacy, and policy making. Using all of these approaches, physicians can play a truly effective role in reducing the burden of injuries for their patients.

An analysis of pediatric trauma deaths in Indiana

From June 1986 to May 1988, there were 1,931 childhood deaths recorded in Indiana. Eight hundred six children (0 to 18 years old) died as a result of trauma (41.4% of all deaths). Seventy percent of all traumatic deaths occurred in boys. Blunt trauma accounted for 54% of deaths, asphyxia or drowning 26%, penetrating trauma 15%, electrocution 3%, and burns 1%. Sixty percent of deaths occurred in rural areas and 40% occurred in urban centers; however, state-wide demographics define the population as 70% urban. The percentage of deaths due to trauma within a given race was: hispanic 71%, caucasian 42%, black 35%, and others 50%. However, when deaths occurring in infants less than 30 days of age were eliminated, the percentages changed: hispanics 70%, caucasian 45%, black 45%, and others 50%. Traumatic deaths were 1.6 times as likely to occur during the months of June through October (n = 85 deaths/mo) as opposed to November through May (n = 53 deaths/mo) (P less than .05). Mortality from burns was limited to children less than 5 years of age and penetrating trauma mortality was twice as likely to occur in children over 15 years (10% v 20%). Fifty-two percent of all traumatic deaths in children occurred between 15 and 18 years of age. Major burns account for only 1% of traumatic deaths in this state. Asphyxia and drowning were more common in young children, and blunt traumatic deaths more common in older children. In 1988, the first state-wide accident awareness program was instituted.(ABSTRACT TRUNCATED AT 250 WORDS)

Paediatric post-injury management: a hospital-based review of deaths

In order to begin to evaluate the need for an integrated trauma management service for injured children, a retrospective review of deaths following admission to a suburban teaching hospital was conducted. The medical records and coroners' reports for 64 consecutive cases over 68 months were reviewed, looking for errors in care which may have contributed to fatal outcomes. There was a male predominance (64%). The main causes of death were pedestrian injuries (42%), drownings (20%), injuries to vehicular passengers (17%) and injuries to cyclists (13%). Errors, often multiple, occurred in 29 cases (45%). Errors most frequently involved airway control and ventilatory support (25%), volume replacement (19%) and delays in performing essential investigations (13%). Errors were most frequent at the referring hospitals (49% [17 of/35 referred cases], compared with 14% at the teaching hospital), and principally involved multiply injured victims of blunt trauma (81%, 13 of 16 patients). In only three cases (5%) would better management have salvaged the patient. This can be explained partly by the predominance of what were judged to be irretrievable intracranial injuries (90%) in patients suffering blunt injuries. In contrast, an analysis of the same patient group revealed that in 30-50% the fatality could have been prevented by the full application of well recognized safety strategies. While strategies such as triage and trauma teams should reduce the error rate, it is yet to be proven that optimal post-injury care will significantly reduce mortality.

Paediatric bicycle injuries

Bicycle injuries are an important cause of trauma. Approximately 75% of such accidents occur in children and involve difficult decisions in the areas of education, engineering and legislation. A prospective 3-year study was undertaken to understand the range of injuries and in particular to concentrate on severe injuries. In all, 251 children were admitted to Westmead Hospital after receiving bicycle injuries. Most injuries were minor but there were 37 serious injuries and six deaths. Head injuries predominated, especially in the seriously injured. The rate of wearing helmets was low, with less than 10% of all admissions wearing a helmet. None of the seriously or fatally injured wore a helmet. Helmet-wearing remains the single most important preventative measure to be instituted if the serious morbidity and mortality rates associated with bicycle injuries are to decrease.