Comparison of pediatric motor vehicle collision injury outcomes at Level I trauma centers

Characteristics and Validation of Pediatric Extremity Vascular Trauma in Dedicated Pediatric and Adult Trauma Centers: A Scoping Review Protocol

BACKGROUND

Pediatric extremity vascular injuries constitute a rare yet serious entity that can lead to serious complications especially if left untreated or become late diagnosed. In our scoping review, we sought to evaluate different characteristics and outcomes of pediatric and combined adult trauma centers (ATCs) in the management of pediatric extremity vascular injury.

METHODS

We sought to analyze various characteristics and parameters that differentiate a dedicated pediatric and a combined pediatric ATC in terms of effectiveness and quality of care in the acute setting and to describe special features and characteristics of an acute vascular disease that constitute pediatric population unique from the aspect of diagnosis and management. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews guidelines to conduct the study.

RESULTS

The search identified 8,815 records in title using MeSH terms from PubMed/MEDLINE database among which 12 studies reporting a total of 2,124 pediatric patients with vascular extremity injuries were included for analysis. Incidence of pediatric extremity vascular injury was 0.5%. Upper extremity injuries were the most frequent presenting in 63% of cases followed by lower extremity injuries in 37% of cases. Blunt injuries were marginally more common than penetrating injuries (58% vs. 42%). In-hospital mortality and morbidity ranged from 13.2% to 0.9% and 13% to 30%, respectively. Limb-salvage rates were high, ranging from 92% to 99%. Furthermore, there are no clearly defined clinical guidelines involving the mode of imaging and diagnosis, the surgical specialties involved and the competency of nursing or medical staff overall.

CONCLUSIONS

Dedicated children trauma centers theoretically represent the optimal path for acute pediatric trauma admission, especially in complex trauma necessitating vascular reconstruction. However, in the current setting of rapidly increasing health costs and economic crisis worldwide, regional or resource-related factors make this option rather unavailable. In any case, it is imperative the clinicians have a high index of suspicion when confronting with these types of injuries because early diagnosis is highly related with reduced morbidity and superior outcomes.

Overcoming Vulnerabilities in Our Emergency Care System Through Pediatric Readiness

Although children account for 20% of all emergency department (ED) visits, the majority of children seek emergency care in hospitals that see fewer than 10 children per day. The National Pediatric Readiness Project has defined key system-level standards for all EDs to safely care for ill and injured children. High pediatric readiness is associated with improvement in mortality for critically ill and injured children. However, to improve readiness and sustain system-level changes, hospitals must invest in pediatric champions and empower them to engage in continuous quality improvement. Finally, incorporating pediatric readiness into policy is crucial for its long-term sustainability.

Management of Children and Adolescents with Chest Trauma in Pediatric and Non-Pediatric Departments—A Claims Data Analysis

Background: To investigate the management of children and adolescents with isolated and combined chest trauma in pediatric (PD) and non-pediatric departments (non-PD). Methods: Anonymized claims data were provided by two large German statutory health insurance funds, covering 6.3 million clients over a 10-year period (2010–2019). Data were extracted for patients who had an inpatient ICD diagnosis of section S20–S29 (injuries to the thorax) and were ≤18 years of age. Demographic and clinical data were analyzed. Results: A total of 4064 children and adolescents with chest trauma were included (mean age 12.0 ± 5.0 years; 55% male). In 1928 cases (47.4%), treatment was provided at PD. Patients admitted to PD underwent CT imaging less frequently (8.1%; non-PD: 23.1%; p < 0.0001). Children with a chest drain treated at university/maximum care hospitals (UM) showed more injuries involving multiple body regions compared with non-UM (25.8% vs. 4.5%; p = 0.0061) without a difference in the length of hospital stay. Conclusion: Children and adolescents with chest trauma are treated almost equally often in pediatric and adult departments. CT is significantly less frequently used in pediatric departments. Patients with a chest drain treated at a UM showed more concomitant injuries without a longer hospital stay. However, the clinical validity of this finding is questionable.

Adding age-adjusted shock index to the American College of Surgeons' trauma team activation criteria to predict severe injury in children

BACKGROUND

The American College of Surgeons (ACS) requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation. Our goal was to evaluate the effect of adding age-adjusted shock index (SI) to the ACS-6 for the prediction of severe injury among pediatric trauma patients with the hypothesis that SI would significantly improve sensitivity with an acceptable decrease in specificity.

METHODS

We performed a secondary analysis of prospectively collected EMS and trauma registry data from two urban pediatric trauma centers. Age-adjusted SI thresholds were calculated as heart rate divided by systolic blood pressure using 2020 Pediatric Advanced Life Support SI vital sign ranges and previously published Shock Index, Pediatric Adjusted (SIPA) thresholds. The primary outcome was a composite of emergency operative (within 1 hour of arrival) or emergency procedural intervention (EOPI) or Injury Severity Score (ISS) greater than 15. Sensitivities, specificities, and 95% CIs were calculated for the ACS-6 alone and in combination with age-adjusted SI.

RESULTS

There were 8,078 patients included; 20% had an elevated age-adjusted SI and 17% met at least one ACS minimum criterion; 1% underwent EOPI; and 17% had ISS >15. Sensitivity and specificity of the ACS-6 for EOPI or ISS > 5 were 45% (95% confidence interval [CI], 41-50%) and 89% (95% CI, 81-96%). Inclusion of Pediatric Advanced Life Support-SI and SIPA resulted in sensitivities of 51% (95% CI, 47-56%) and 69% (95% CI, 65-72%), and specificities of 80% (95% CI, 71-89%) and 60% (95% CI, 53-68%), respectively. Similar trends were seen for each secondary outcome.

CONCLUSION

In this cohort of pediatric trauma registry patients, the addition of SIPA to the ACS-6 for trauma team activation resulted in significantly increased sensitivity for EOPI or ISS greater than 15 but poor specificity. Future investigation should explore using age-adjusted shock index in a two-tiered trauma activation system, or in combination with novel triage criteria, in a population-based cohort.

LEVEL OF EVIDENCE

Diagnostic Tests or Criteria; Level II.

Elder child or young adult? Adolescent trauma mortality amongst pediatric and adult facilities

BACKGROUND

While it is assumed adolescents receive comparable trauma care at pediatric trauma centers (PTC), adult trauma centers (ATC), and combined facilities (MTC), this remains understudied.

METHODS

We conducted a retrospective cohort study through the NTDB evaluating patients 14-18 years of age who presented to an ACS-verified level 1 or 2 trauma facility between 1/1/2016 and 12/31/2019. Multiple logistic regression analyses were performed to compare mortality risk among trauma facility verification types.

RESULTS

91,881 adolescents presented after trauma over the four-years. Hypotension, severe TBI, firearm mechanism, and ISS >15 were associated with increased mortality. Compared to PTCs, the odds of trauma-related mortality were statistically higher at MTCs (OR 1.82, p = 0.004) and ATCs (OR 1.89-2.05, p = 0.001-0.002).

CONCLUSIONS

Injured adolescents receiving care at ATCs and MTCs have higher mortality risk than those cared for at PTCs. Further evaluation of factors associated with this observed difference is warranted and may help identify opportunities to improve outcomes in injured adolescents.

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

INTRODUCTION

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Association between access to pediatric trauma care and motor vehicle crash death in children: An ecologic analysis of United States counties

BACKGROUND

Access to pediatric trauma care is highly variable across the United States. The purpose of this study was to measure the association between pediatric trauma center care and motor vehicle crash (MVC) mortality in children (<15 years) at the US county level for 5 years (2014-2018).

METHODS

The exposure was defined as the highest level of pediatric trauma care present within each county: (1) pediatric trauma center, (2) adult level 1/2, (3) adult level 3, or (4) no trauma center. Pediatric deaths due to passenger vehicle crashes on public roads were identified from the NHTSA Fatality Analysis Reporting System. Hierarchical negative binomial modeling measured the relationship between highest level of pediatric trauma care and pediatric MVC mortality within counties. Adjusted analyses accounted for population age and sex, emergency medical service response times, helicopter ambulance availability, state traffic safety laws, and measures of rurality.

RESULTS

During the study period 3,067 children died in fatal crashes. We identified 188 pediatric trauma centers in 141 counties. Significant disparities in access to pediatric trauma care were observed. Specifically, 99% of pediatric trauma centers were situated in population-dense urban counties, while 28% of children lived in counties no trauma center. After risk adjustment, counties with pediatric trauma centers had significantly lower rates of pediatric MVC death than those with no trauma center: 0.7 versus 3.2 deaths/100,000 child-years; mortality rate ratio, 0.58; and 95% confidence interval, 0.39 to 0.86. In counties where pediatric trauma centers were absent, adult level 1/2 trauma centers were associated with comparable risk reduction.

CONCLUSION

The presence of pediatric trauma centers was associated with lower rates of MVC death in children. Adult level 1/2 trauma centers appear to offer comparable risk reduction. Where population differences in pediatric trauma mortality are observed, addressing disparities in county-level access to pediatric trauma care may serve as a viable target for system-level improvement.

LEVEL OF EVIDENCE

Epidemiological, level III; Care management, level III.

Facial Protection to Prevent Facial Trauma and Allow for Optimal Protection after Facial Fracture Repair

Facial skeletal fractures continue to affect humankind, and many methods to alleviate and prevent the injuries outright have been sought after. Prevention is desired, but the implementation and general compliance may contribute to missed opportunities to decrease the burden of facial skeletal trauma. In this article, we explore the preventative as well as postoperative options for the protection of the facial skeleton.

The Association of Glasgow Coma Scale Score With Clinically Important Traumatic Brain Injuries in Children

OBJECTIVE

An accurate understanding of the incidence of clinically important traumatic brain injuries (ciTBIs) based on presenting Glasgow Coma Scale (GCS) scores in pediatric patients is required to formulate a pretest probability of disease to guide testing and treatment. Our objective was to determine the prevalence of ciTBI and neurosurgical intervention for each GCS score (range 3-15) in children presenting after blunt head trauma.

METHODS

This was a secondary analysis of prospectively collected observational data from 25 pediatric emergency departments in the Pediatric Emergency Care Applied Research Network. Patients younger than 18 years with nontrivial blunt head injury were included.

RESULTS

A total of 43,379 children with complete GCS scores were included in the analysis. Seven hundred sixty-three children had ciTBIs (1.8%) and 200 underwent neurosurgery (0.5%). Children with GCS scores of 4 had the highest incidence of ciTBI (21/22, 95.5%) and neurosurgical intervention (16/22, 72.2%). A nearly linear decrease in the prevalence of ciTBI from a GCS score of 4 to a score of 15 was observed (R = 0.92). Of 1341 children, 107 (8.0%) presenting with GCS scores of 14 were found to have ciTBIs and 17 (1.3%) underwent neurosurgical intervention.

CONCLUSIONS

A nearly linear relationship exists between the initial GCS score and ciTBI in children with blunt head trauma. The highest prevalence of ciTBI and neurosurgical intervention occurred in children with GCS scores of 4. Children presenting with GCS scores of 14 had a nonnegligible prevalence of ciTBI. These findings are critical to providers caring for children with blunt head trauma to accurately formulate pretest probabilities of ciTBI.

Road Traffic Accidents and Disparities in Child Mortality

BACKGROUND AND OBJECTIVES

Road traffic accidents are a leading cause of child deaths in the United States. Although this has been examined at the national and state levels, there is more value in acquiring information at the county level to guide local policies. We aimed to estimate county-specific child mortality from road traffic accidents in the United States.

METHODS

We queried the Fatality Analysis Reporting System database, 2010-2017, for road traffic accidents that resulted in a death within 30 days of the auto crash. We included all children <15 years old who were fatally injured. We estimated county-specific age- and sex-standardized mortality. We evaluated the impact of the availability of trauma centers and urban-rural classification of counties on mortality.

RESULTS

We included 9271 child deaths. Among those, 45% died at the scene. The median age was 7 years. The overall mortality was 1.87 deaths per 100 000 children. County-specific mortality ranged between 0.25 and 21.91 deaths per 100 000 children. The availability of a trauma center in a county was associated with decreased mortality (adult trauma center [odds ratio (OR): 0.59; 95% credibility interval (CI), 0.52-0.66]; pediatric trauma center [OR: 0.56; 95% CI, 0.46-0.67]). Less urbanized counties were associated with higher mortality, compared with large central metropolitan counties (noncore counties [OR: 2.33; 95% CI, 1.85-2.91]).

CONCLUSIONS

There are marked differences in child mortality from road traffic accidents among US counties. Our findings can guide targeted public health interventions in high-risk counties with excessive child mortality and limited access to trauma care.

Pediatric emergency department readiness among US trauma hospitals

BACKGROUND

Pediatric readiness among US emergency departments is not universal. Trauma hospitals adhere to standards that may support day-to-day readiness for children.

METHODS

In 2013 4,146 emergency departments participated in the NPRP to assess compliance with the 2009 Guidelines to Care for Children in the Emergency Department. Probabilistic linkage (90%) to the 2009 American Hospital Association survey found 1,247 self-identified trauma hospitals (levels 1, 2, 3, 4). Relationship between trauma hospital level and weighted pediatric readiness score (WPRS) on a 100-point scale was performed; significance was assessed using a Kruskal-Wallis test and pediatric readiness elements using χ. Adjusted relative risks were calculated using modified Poisson regression, controlling for pediatric volume, hospital configuration, and geography.

RESULTS

The overall WPRS among all trauma hospitals (1,247) was 71.8. Among those not self-identified as a children's hospital or emergency department approved for pediatrics (EDAP) (1088), Level 1 and 2 trauma hospitals had higher WPRS than level 3 and 4 trauma hospitals, 83.5 and 71.8, respectively versus 64.9 and 62.6. Yet, compared with EDAP trauma hospitals (median 90.5), level 1 general trauma hospitals were less likely to have critical pediatric-specific elements. Common gaps among general trauma hospitals included presence of interfacility transfer agreements for children, measurement of pediatric weights solely in kilograms, quality improvement processes with pediatric-specific metrics, and disaster plans that include pediatric-specific needs.

CONCLUSION

Self-identified trauma hospital level may not translate to pediatric readiness in emergency departments. Across all levels of general non-EDAP, nonchildren's trauma hospitals, gaps in pediatric readiness exist. Nonchildren's hospital EDs (i.e., EDAPs) can be prepared to meet the emergency needs of all children and trauma hospital designation should incorporate these core elements of pediatric readiness.

LEVEL OF EVIDENCE

Care management, level III.

Children after motor vehicle crashes: Restraint utilization and injury severity

BACKGROUND

Although injury patterns after motor vehicle crashes (MVCs) are well documented, association between adequate restraint and injury severity is unclear. We aimed to determine if improper restraint affects injury rates and severity.

METHODS

A retrospective chart review of 477 children hospitalized in Pediatric Trauma Center after MVC was performed. Injuries in various age groups (0-7, 8-12, 13-16, 17-18 years) with different restraint quality measures (proper [PR] and improper/unrestrained [IUR]) as well as injury severity score (ISS: mild [1-9], moderate [10-15], severe [16-25], and profound [>25]) were evaluated and compared. Chi-square and Wilcoxon rank-sum tests were used for statistics.

RESULTS

In all age groups head/neck injuries were most common (55-63%), while abdominal and pelvic injuries were least likely except group 8-12 years where abdominal injuries ranked third (17.1%). Overall, 64.5% had PR and 35.5% IUR. Interestingly, that greatest proportion of IUR was in the youngest age group (0-7). It decreased with aging and children aged 17-18 years were significantly less likely to be IUR compared to those 0-7 years (OR[odds ratio] = 0.58; 95%CI[confidence interval] 0.35-0.94). We did not find significant differences in rates of various injuries between PR and IUR. However, ISS severity in IUR was significantly greater than in PR (median with interquartile range 6(2-14) and 5(1-9), respectively; P = 0.001). As a result, IUR compared to PR were less likely to have mild ISS (OR = 0.6, 95%CI 0.39-0.90) but more likely to have profound ISS (OR = 3.3, 95%CI 1.48-7.43).

CONCLUSION

Restraint quality has significant impact on injury severity in children after MVC.

LEVEL OF EVIDENCE

Level III.

High volume crystalloid resuscitation adversely affects pediatric trauma patients

BACKGROUND

Aggressive fluid resuscitative strategies have been the cornerstone of early trauma management for decades. However, recent prospective adult studies have challenged this practice, underlining the detrimental effect of positive fluid balance on cardiopulmonary function. Fluid overload has been associated with impaired oxygenation and morbidity in critically ill adults, but data is lacking in pediatric trauma patients.

METHODS

We completed a retrospective chart review of all pediatric trauma patients 0-18 years old admitted to a level 1 trauma center from January 2013 to December 2015. Four patient cohorts were established based on volume of fluid administered: <20 ml/kg/day, 20-40 ml/kg/day, 40-60 ml/kg/day, and > 60 ml/kg/day. The primary outcome was death. Secondary outcomes included the number of days on the ventilator, intensive care unit length of stay (ICU LOS), overall length of stay (LOS), number of days nil per os (NPO) as an indicator of ileus, and incidence of bloodstream infection and/or surgical site infection.

RESULTS

The mean volume of fluid administered over the first 24 h was 41 ml/kg/day, and 28 ml/kg/day over the first 48 h. ICU length of stay and overall length of stay were increased in patients who received more than 60 ml/kg/day in the first 24 h of their hospitalization. Furthermore, ventilator use, ICU length of stay, overall length of stay, and time to resumption of a regular diet were all increased in patients who received >60 ml/kg/day over 48 h.

CONCLUSIONS

Early administration of high volumes of crystalloid fluid greater than 60 ml/kg/day significantly correlates with pulmonary complications, days NPO, and hospital length of stay. These results span the first 48 h of a patient's hospital stay and should encourage surgical care providers to exercise judicious use of crystalloid fluid administration in the trauma bay, ICU, and floor.

TYPE OF STUDY

Therapeutic.

LEVEL OF EVIDENCE

Level III.

Injury-Related Healthcare Use and Risk of Filicide Victimization: A Population-Based Case-Control Study

Research on child-related risk factors for filicide is scant. We investigated whether prior healthcare use for injury (including poisoning) influences filicide risk. Victims (0-14 years; n = 71) were identified in a national autopsy database for the years 1994-2012 and compared to matched, general population controls (n = 355). Healthcare use data were retrieved from a national patient registry. Risks were estimated using odds ratios (ORs) and 95% confidence intervals (CIs). For females, prior inpatient care for injury conferred a statistically significant sevenfold risk (OR = 6.67 [95% CI: 1.49-29.79]), and any prior injury-related healthcare use conferred a statistically significant fourfold risk (OR = 3.57 [95% CI: 1.13-11.25]), of filicide victimization. No statistically significant risks were found for males. Healthcare personnel should be aware that children treated for injuries, especially females, may be at an elevated risk of filicide victimization. Nevertheless, the filicide base rate remains low, and parents may be stigmatized by unfounded alerts; thus, prudent reflection should precede reports to the authorities.

Severe traumatic brain injuries in children: Does the type of trauma center matter?

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of death among injured children. Depending on geographic location, and trauma resources, pediatric patients may be treated at pediatric (PTC), adult (ATC), or mixed trauma centers (MTC). The effect of the type of trauma center on outcomes in severe TBI is not known.

METHODS

NTDB study (2007-2014), level 1 trauma centers, patients ≤14years with severe isolated TBI (head AIS≥3 and extracranial AIS≤2). Demographic, clinical and injury characteristics were abstracted. Logistic regression was used to compare outcomes between the three types of trauma centers.

RESULTS

10,402 patients met inclusion criteria. 4430 (42.6%) were admitted in PTC, 4044 (38.9%) in ATC and 1928 (18.5%) in MTC. Overall, 39.9% of patients had head AIS 3, 55.5% had AIS 4 and 4.6% AIS 5. Mortality was 3.2% (2.0% in PTC, 4.5% in ATC and 3.3% in MTC). On logistic regression, treatment at ATC was associated with significantly higher mortality than PTC (OR 1.55, p=0.011). There was no significant difference between PTC and MTC (p=0.394). There was no significant difference in mortality between the 3 types of trauma centers in the subgroups of patients with head AIS 3 or 5. However, patients with head AIS 4 treated at MTC had significantly lower mortality (OR 0.163, 95% CI 0.053-0.501, p=0.002).

CONCLUSION

Patients with isolated severe TBI treated at PTC have significantly better survival than patients treated at ATC, but not MTC. In the subgroup of patients with isolated TBI and a head AIS score of 4, patients treated at MTC have improved survival than those treated at PTC.

LEVEL OF EVIDENCE

III.

The epidemiology of inpatient pediatric trauma in United States hospitals 2000 to 2011

BACKGROUND

This study provides important updates to the epidemiology of pediatric trauma in the United States.

METHODS

Age-specific epidemiologic analysis of the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample, representing 2.4 million pediatric traumatic injury discharges in the US from 2000 to 2011. We present yearly data with overlying loess smoothing lines, proportions of common injuries and surgical procedures, and survey-adjusted logistic regression analysis.

RESULTS

From 2000 to 2011 there was a 21.7% decline in US pediatric trauma injury inpatient discharges from 273.2 to 213.7 admissions per 100,000. Inpatient case-fatality decreased 5.5% from 1.26% (95% CI 1.05-1.47) to 1.19% (95% CI 1.01-1.38). Severe injuries accounted for 26.5% (se=0.11) of all discharges in 2000 increasing to 31.3% (se=0.13) in 2011. The most common injury mechanism across all age groups was motor vehicle crashes (MVCs), followed by assaults (15-19years), sports (10-14), falls (5-9) and burns (<5). The total injury-related, inflation-adjusted cost was $21.7 billion, increasing 56% during the study period.

CONCLUSIONS

The overall rate of inpatient pediatric injury discharges across the United States has been declining. While injury severity is increasing in hospitalized patients, case-fatality rates are decreasing. MVCs remain a common source of all pediatric trauma.

LEVELS OF EVIDENCE

Level III.