Mortality after emergency department thoracotomy for pediatric blunt trauma: Analysis of the National Trauma Data Bank 2007-2012

Emergency department thoracotomy in children: A Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma systematic review and practice management guideline

BACKGROUND

The role of emergency department resuscitative thoracotomy (EDT) in traumatically injured children has not been elucidated. We aimed to perform a systematic review and create evidence-based guidelines to answer the following PICO (population, intervention, comparator, and outcome) question: should pediatric patients who present to the emergency department pulseless (with or without signs of life [SOL]) after traumatic injuries (penetrating thoracic, penetrating abdominopelvic, or blunt) undergo EDT (vs. no EDT) to improve survival and neurologically intact survival?

METHODS

Using Grading of Recommendations Assessment, Development and Evaluation methodology, a group of 12 pediatric trauma experts from the Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma assembled to perform a systematic review. A consensus conference was conducted, a database was queried, abstracts and manuscripts were reviewed, data extraction was performed, and evidence quality was determined. Evidence tables were generated, and the committee voted on guideline recommendations.

RESULTS

Three hundred three articles were identified. Eleven studies met the inclusion criteria and were used for guideline creation, providing 319 pediatric patients who underwent EDT. No data were available on patients who did not undergo EDT. For each PICO, the quality of evidence was very low based on the serious risk of bias and serious or very serious imprecision.

CONCLUSION

Based on low-quality data, we make the following recommendations. We conditionally recommend EDT when a child presents pulseless with SOL to the emergency department following penetrating thoracic injury, penetrating abdominopelvic injury and after blunt injury if emergency adjuncts point to a thoracic source. We conditionally recommend against EDT when a pediatric patient presents pulseless without SOL after penetrating thoracic and penetrating abdominopelvic injury. We strongly recommend against EDT in the patient without SOL after blunt injury.

Torso vascular trauma

Vascular injury within the chest or abdomen represents a unique challenge to the pediatric general surgeon, as these life- or limb-threatening injuries are rare and may require emergent treatment. Vascular injury may present as life-threatening hemorrhage, or with critical ischemia from intimal injury, dissection, or thrombosis. Maintaining the skillset and requisite knowledge to address these injuries is of utmost importance for pediatric surgeons that care for injured children, particularly for surgeons practicing in freestanding children's hospitals that frequently do not have adult vascular surgery coverage. The purpose of this review is to provide an overview of torso vascular trauma, with a specific emphasis in rapid recognition of torso vascular injury as well as both open and endovascular management options. Specific injuries addressed include blunt and penetrating mediastinal vascular injury, subclavian injury, abdominal aortic and visceral segment injury, inferior vena cava injury, and pelvic vascular injury. Operative exposure, vascular repair techniques, and damage control options including preperitoneal packing for pelvic hemorrhage are discussed. The role and limitations of endovascular treatment of each of these injuries is discussed, including endovascular stent graft placement, angioembolization for pelvic hemorrhage, and resuscitative endovascular balloon occlusion of the aorta (REBOA) in children.

Ethical challenges with decisions to withhold or withdraw resuscitation in pediatric surgery

Providers often dispute the ethical equivalence of withholding and withdrawing care, despite theoretical frameworks that support equivalency. We highlight two cases, one where providers express concern with initiation of aggressive resuscitation and another where providers experience emotional distress from the decision to cease resuscitation. Both cases illustrate how the ethical challenges encountered can result in high levels of provider distress. Mitigation of this moral distress by team members will require an improved understanding of available evidence in the literature and active discussion by debriefing after a child dies. Medical staff and national organizations can help recognize that these patient events contribute to provider burnout and facilitate the design and support of programs to increase provider resiliency.

Quantifying the need for pediatric REBOA: A gap analysis

BACKGROUND

Trauma is the leading cause of death in children. Resuscitative endovascular balloon occlusion of the aorta (REBOA) provides temporary hemorrhage control, but its potential benefit has not been assessed in children. We hypothesized that there are pediatric patients who may benefit from REBOA.

METHODS

Trauma patients <18 years old at a level 1 pediatric trauma center between 2009 and 2019 were queried for deaths, pre-hospital cardiac arrest, massive transfusion protocol activation, transfusion requirement, or hemorrhage control surgery. These patients defined the cohort of severely injured patients. From this cohort, patients with intraabdominal injuries for which REBOA may provide temporary hemorrhage control were identified, including solid organ injury necessitating intervention, vascular injury, or pelvic hemorrhage.

RESULTS

There were 239 severely injured patients out of 6538 pediatric traumas. Of these, 38 had REBOA-amenable injuries (15.9%) with 34.2% mortality, accounting for 10.2% of all pediatric trauma deaths at one center. Eleven patients with REBOA-amenable injuries had TBI (28.9%). Patients with REBOA-amenable injuries represented 0.6% of all pediatric traumas.

CONCLUSION

Nearly 20% of severely injured pediatric patients could potentially benefit from REBOA. The overall proportion of pediatric patients with REBOA-amenable injuries is similar to adult studies.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Causes of early mortality in pediatric trauma patients

BACKGROUND

Trauma is the leading cause of death in children, and most deaths occur within 24 hours of injury. A better understanding of the causes of death in the immediate period of hospital care is needed.

METHODS

Trauma admissions younger than 18 years from 2009 to 2019 at a Level I pediatric trauma center were reviewed for deaths (n = 7,145). Patients were stratified into ages 0-6, 7-12, and 13-17 years old. The primary outcome was cause of death, with early death defined as less than 24 hours after trauma center arrival.

RESULTS

There were 134 (2%) deaths with a median age of 7 years. The median time from arrival to death was 14.4 hours (interquartile range, 0.5-87.8 hours). Half (54%) occurred within 24 hours. However, most patients who survived initial resuscitation in the emergency department died longer than 24 hours after arrival (69%). Traumatic brain injury was the most common cause of death (66%), followed by anoxia (9.7%) and hemorrhage (8%). Deaths from hemorrhage were most often in patients sustaining gunshot wounds (73% vs. 11% of all other deaths, p < 0.0001), more likely to occur early (100% vs. 50% of all other deaths, p = 0.0009), and all died within 6 hours of arrival. Death from hemorrhage was more common in adolescents (21.4% of children aged 13-17 vs. 6.3% of children aged 0-6, and 0% of children aged 7-12 p = 0.03). The highest case fatality rates were seen in hangings (38.5%) and gunshot wounds (9.6%).

CONCLUSION

Half of pediatric trauma deaths occurred within 24 hours. Death from hemorrhage was rare, but all occurred within 6 hours of arrival. This is a critical time for interventions for bleeding control to prevent death from hemorrhage in children. Analysis of these deaths can focus efforts on the urgent need for development of new hemorrhage control adjuncts in children.

LEVEL OF EVIDENCE

Epidemiological study, level IV.

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.

Resuscitative endovascular balloon occlusion of the aorta (REBOA) for temporization of hemorrhage in adolescent trauma patients

BACKGROUND/PURPOSE

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has emerged as an alternative technique for traumatic hemorrhage control in the adult population. The purpose of this study is to describe the details of REBOA placement in adolescent trauma patients.

METHODS

Patients 18 years of age or less who received REBOA for aortic occlusion (AO) from August 2013 to February 2017 at 2 urban tertiary care centers were included.

RESULTS

7 adolescent trauma patients received REBOA by trauma surgeons for both blunt (n = 4) and penetrating mechanisms (n = 3); mean age was 17 + 1.5 years, mean admission lactate 13.0 + 4.85 mmol/L, and mean Hgb 10.7 + 2.7 g/dL. 3 patients received REBOA through a 12Fr sheath and 4 through a 7Fr sheath. AO occurred mostly at the distal thoracic aorta (Zone I) (85.7%) and also in the distal abdominal aorta (Zone III) (14.3%). 57% of patients were in arrest with ongoing CPR at the time of REBOA. In-hospital mortality was 57%; all of these patients were in arrest at the time of REBOA, had return of spontaneous circulation (ROSC), and survived to the operating room. No complications from REBOA were identified.

CONCLUSION

REBOA appears to be feasible for use in adolescents despite their smaller caliber vessels, even with use of a 12Fr sheath. REBOA results in improved physiology and can bridge adolescent trauma patients presenting in extremis to the operating room.

TYPE OF STUDY

Treatment/therapeutic study LEVEL OF EVIDENCE: Level IV.

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

BACKGROUND

Emergent procedures are infrequent in pediatric trauma. We sought to determine the frequency and efficacy of life-saving interventions (LSI) performed for pediatric trauma patients within the first hour of care at a trauma center.

METHODS

The National Trauma Data Bank (2010-2014) was queried for patients 19 years or younger who underwent LSIs within 1 hour of arrival to the emergency department. Life-saving interventions included emergency department thoracotomy (EDT) and emergent airway procedures (EAP). Multivariable logistic regression was used to evaluate the influence of patient and hospital characteristics on mortality.

RESULTS

Of 725,284 recorded traumatic encounters, only 1,488 (0.2%) pediatric patients underwent at least one of the defined LSI during the 5-year study period (EDT, 1,323; EAP, 187). Most patients (85.6%) were 15 years or older. Mortality was high but varied by procedure type (EDT, 64.3%; EAP, 28.3%). Mortality for patients younger than 1 year undergoing EDT was 100%, decreasing to 62.6% in patients aged 15 years to 19 years. For EAP, mortality ranged from 66.7% for infants to 27.2% in 15-year-old to 19-year-old patients. Lower Glasgow Coma Scale score, higher Injury Severity Score, presence of shock, and a blunt mechanism of injury were independently associated with mortality in the EDT cohort. On average, trauma centers in this study performed approximately one LSI per year, with only 13.8% of cases occurring at a verified pediatric trauma center.

CONCLUSION

Life-saving interventions in the pediatric trauma population are uncommon and outcomes variable. Novel solutions to keep proficient at such interventions should be sought, especially for younger children. Guidelines to improve identification of appropriate candidates for LSI are critical given their rare occurrence.

LEVEL OF EVIDENCE

Retrospective cohort study, III.

Nationwide trends in mortality following penetrating trauma: Are we up for the challenge?

BACKGROUND

Despite a focus on improved prehospital care, penetrating injuries contribute substantially to trauma mortality in the United States. We therefore analyzed contemporary trends in prehospital mortality from penetrating trauma in the past decade.

METHODS

We identified patients in the The National Trauma Data Bank from 2007 to 2010 ("early period") and 2011 to 2014 ("late period") with gunshot wounds (GSW) and stab wounds (SW), who were treated at hospitals that recorded dead-on-arrival statistics. Multivariable logistic regressions assessed differences in body locations of trauma, prehospital mortality, and in-hospital mortality between the early and late periods. Models accounted for hospital clusters and adjusted for age, pulse, hypotension, New Injury Severity Score, Glasgow Coma Scale, and number of injured body parts.

RESULTS

From 2007 to 2014, 437,398 patients experienced penetrating traumas, with equal distributions of GSW and SW. There were unadjusted differences in prehospital mortality (GSW: early, 2.0% vs. late, 4.9%; SW: early, 0.2% vs. late, 1.1%) and in-hospital mortality (GSW: early, 13.8% vs. late, 9.5%; SW: early, 1.8% vs. late, 1.0%) by both mechanisms. After adjustment, patients in the late period relative to those in the early period had significantly higher odds of prehospital death (GSWs: adjusted odds ratio [aOR], 4.54; 95% confidence interval [CI], 3.31-6.22; SWs: aOR, 8.98; 95% CI, 5.50-14.67) and lower odds of in-hospital death (GSWs: aOR, 0.85; 95% CI, 0.80-0.90; SWs: aOR, 0.81; 95% CI, 0.71-0.92). Sensitivity analyses assessing GSWs and SWs by locations of body injury found similar results. Additionally, patients in the late period were more likely to experience penetrating injuries to the face, spine, and lower extremities.

CONCLUSION

In the United States, the prevalence of penetrating traumas remains a nationwide burden. The odds of prehospital mortality has increased over fourfold for GSWs and almost ninefold for SWs. Examining violence intensity, along with improvements in hospital care and data collection, may explain these findings.

LEVEL OF EVIDENCE

Prognostic and epidemiological, level IV.

Survival after emergency department thoracotomy in the pediatric trauma population: a review of published data

BACKGROUND/PURPOSE

The utility of EDT in the adult trauma population, using well-defined guidelines, is well established, especially for penetrating injuries. Since the introduction of these guidelines, reports on the use of EDT for pediatric trauma have been published, and these series reveal a dismal, almost universally fatal, outcome for EDT following blunt trauma in the child. This report reviews the clinical outcomes of EDT in the pediatric population.

MATERIALS/METHODS

We performed a review of EDT in the pediatric population using the published data from 1980 to 2017. Variables extracted included mechanism of injury and mortality. To minimize bias, single case reports were not included in the review.

RESULTS

Upon review of four decades of published literature on the use of emergency department thoracotomy (EDT) in the pediatric population, mortality rates are comparable between adults and pediatric patients for penetrating thoracic trauma. In contrast, in pediatric patients sustaining blunt trauma, no patient under the age of 15 has survived.

CONCLUSION

In patients between 0 and 14 years of age presenting with no signs of life following blunt trauma, withholding EDT should be considered. Patients between the ages of 15 and 18 should be treated in accordance with adult ATLS principles for the management of thoracic trauma.

LEVEL OF EVIDENCE

Level IV.