Prehospital care and transportation of pediatric trauma patients

Prehospital time and mortality in pediatric trauma

PURPOSE

The "Golden Hour" of transportation to a hospital has long been accepted as a central principal of trauma care. However, this has not been studied in pediatric populations. We assessed for non-linearity of the relationship between prehospital time and mortality in pediatric trauma patients, redefining the threshold at which reducing this time led to more favorable outcomes.

METHODS

We performed an analysis of the 2017-2018 American College of Surgeons Trauma Quality Improvement Program, including trauma patients age < 18 years. We examined the association between prehospital time and odds of in-hospital mortality using linear, polynomial, and restricted cubic spline (RCS) models, ultimately selecting the non-linear RCS model as the best fit.

RESULTS

60,670 patients were included in the study, of whom 1525 died and 3074 experienced complications. Prolonged prehospital time was associated with lower mortality and fewer complications. Both models demonstrated that mortality risk was lowest at 45-60 min, after which time was no longer associated with reduced probability of mortality.

CONCLUSIONS

The demonstration of a non-linear relationship between pre-hospital time and patient mortality is a novel finding. We highlight the need to improve prehospital treatment and access to pediatric trauma centers while aiming for hospital transportation within 45 min.

A comparative study on specialized services in pre-hospital emergencies in Iran and selected countries

The quality of emergency services is one of the indicators describing the health status of countries. Moreover, the specialization of services and targeted response to any accident or disease has been the priority of pre-hospital emergency operations in some leading countries. This study aimed to compare the special services provided in the emergency department of several selected countries. This was a comparative study that was done in Isfahan in 2022. Data were collected by reviewing the literature provided by libraries and emergency websites of selected countries. We selected countries based on the accessibility of information in two groups of developed countries and countries with the same income and population as Iran including Germany, France, The United States, Australia, Britain, Malaysia, and Turkey. Data were classified and compared based on staff, vehicles, and specialized services. Emergency staffs in most countries were of different skill and training levels. Ambulances varied in equipment types in various land, air, and sea forms and dimensions. Developed countries had more modern ambulances and equipment. France and Germany were operating more especially. Specialized teams are dispatched only in the United States and Germany. Existing studies have shown the adequacy and effectiveness of these teams in reducing complications and mortality and improving the prognosis of patients. The use of specialized teams appropriate to each emergency based on the specific and targeted response is effective in improving the prognosis of patients. The results of this study are suggested to beneficiaries to improve the quality of emergency care and reduce complications and potential causalities.

Preclinical Pediatric Care by Emergency Physicians: A Comparison of Trauma and Nontrauma Patients in a Population-Based Study in Austria

OBJECTIVES

Fewer than 10% of emergency medical system (EMS) calls concern children and adolescents younger than 18 years. Studies have shown that the preclinical care of children differs from that of adults regarding assessment, interventions, and monitoring. The aims of this study were to describe the preclinical care and emergency transport of pediatric patients in Vorarlberg, Austria and to compare trauma and nontrauma cases.

METHODS

This is a population-based study, analyzing medical records of EMS calls to children and adolescents. We received all patient records of EMS calls to children and adolescents younger than 18 years (n = 4390 in total) from the 2 local EMS providers, the Red Cross Vorarlberg and the Austrian Mountain Rescue Service (Christophorus 8 and Gallus 1) covering a study period of 7 years, from 2013 to 2019. The record data were extracted by automation with an in-house program and subsequently anonymized. Statistical analyses were performed with SPSS Statistics.

RESULTS

During the study period, 7.9% of all EMS calls concerned children and adolescents younger than 18 years. For our study, 3761 records were analyzed and 1270 trauma cases (33.8%) were identified. The most common injuries were injuries of the extremities and traumatic brain injury. The frequency of National Advisory Committee of Aeronautics Scores of 4 or higher was 17.7%, similar for all age groups and for trauma as well as nontrauma patients. Mean Glasgow Coma Scale scores were higher in the trauma group than in the nontrauma group (14.2 vs 11.2). In 62.9% of all patients, 1 or more vital parameters were documented. A majority of these values was in the pathologic range for the respective age group. The rate of pulsoxymetry monitoring during transport was low (42.1% in trauma and 30.3% in nontrauma patients) and decreased significantly with patient age. Moreover, while the placing of intravenous lines and monitoring during transport were significantly more frequent in trauma patients, the administration of medication or oxygen was significantly more frequent in nontrauma patients.

CONCLUSIONS

The pediatric population lacks assessments and monitoring in preclinical care, especially the youngest children and nontrauma patients, although emergency severity scores are similar.

Association of transport time with adverse outcome in paediatric trauma

Background

It is unclear how the length of prehospital transport time affects outcome in paediatric trauma. This study evaluated the association of transport time from alarm to arrival at hospital with adverse outcome in paediatric trauma patients in Sweden.

Methods

This was a retrospective study based on prospectively collected data from the Swedish trauma registry between 2012 and 2019 of children less than 18 years with major trauma (New Injury Severity Score (NISS) greater than 15). The primary outcome was 30-day mortality, and secondary outcomes were emergency interventions (e.g., chest tube or laparotomy) and low functional outcome (Glasgow Outcome Scale 2–3). Primary exposure was transport time from alarm to arrival at hospital. Co-variables in multivariable regressions were gender, age, ASA score before injury, injury intention, dominant injury type, NISS, Glasgow Coma Scale score, prehospital competence and hospital level.

Results

Among 597 patients, 30-day mortality was 9.8 per cent, emergency interventions were performed in 34.7 per cent and low functional outcome was registered in 15.9 per cent. Median transport time was 51 (i.q.r. 37–68) minutes. After adjustment for patient, injury and hospital characteristics, no association between longer transport time and 30-day mortality, frequency of emergency interventions or lower functional outcome could be found. Treatment at a university hospital was associated with a lower risk for 30-day mortality (odds ratio 0.23 (95 per cent c.i. 0.08 to 0.68), P = 0.008).

Conclusion

Longer transport time after major paediatric trauma was not associated with adverse outcome. Hence, it seems that longer transport distances should not be an obstacle against centralization of paediatric trauma care. Further studies should focus on the role of prehospital competence and other transport-associated parameters and their association with adverse outcome.

Prehospital Life-Saving Interventions Performed on Pediatric Patients in a Combat Zone: A Multicenter Prospective Study

OBJECTIVES

We aimed to describe and evaluate prehospital life-saving interventions performed in a pediatric population in the Afghanistan theater of operations.

DESIGN

Our study was a post hoc, subanalysis of a larger multicenter, prospective, observational study.

SETTING

We evaluated casualties enrolled upon admission to one of the nine military medical facilities in Afghanistan between January 2009 and March 2014.

PATIENTS

Adult and pediatric (<17 yr old) patients.

MEASUREMENTS

We conducted initial descriptive analyses followed by comparative tests. For comparative analysis, we stratified the study population (adult vs pediatric), and subsequently, we compared injury descriptions and the interventions performed. Following tests for normality, we used the t test or Wilcoxon rank-sum test (nonparametric) for continuous variables and chi-square or Fisher exact for categorical variables. We reported percentages and 95% CIs.

MAIN RESULTS

We enrolled 2,106 patients, of which 5.6% (n = 118) were pediatric. Eighty-two percent of the pediatric patients were male, and 435 had blast related injuries. A total of 295 prehospital life-saving interventions were performed on 118 pediatric patients, for an average of 2.5 life-saving interventions per patient. Vascular access (IV 96%, intraosseous 91%) and hypothermia prevention-related interventions (69%) were the most common. Incorrectly performed life-saving interventions in pediatric patients were rare (98% of life-saving interventions performed correctly) and n equals to 24 life-saving interventions over the 6-year period were missed. The most common incorrectly performed and missed life-saving interventions were related to vascular access. When compared with adult life-saving interventions received in the prehospital environment, pediatric patients were more likely to receive intraosseous access (p < 0.0001), whereas adult patients were more likely to have a tourniquet placed (p = 0.0019), receive wound packing with a hemostatic agent (p = 0.0091), and receive chest interventions (p = 0.0003).

CONCLUSIONS

In our study, the most common intervention was vascular access followed by hypothermia prevention and hemorrhage control. The occurrence of missed or incorrectly performed life-saving interventions were rare.

U.S. Military Medical Evacuation and Prehospital Care of Pediatric Trauma Casualties in Iraq and Afghanistan

Background: Traumatic injuries were the most common reason for pediatric admission to military hospitals during the recent wars in the Middle East. We describe injury characteristics and prehospital interventions performed on wartime pediatric trauma casualties in Afghanistan and Iraq, stratified by medical evacuation platform. Methods: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric (age < 18 years) encounters from January 2007 to January 2016. The DODTR is the data repository for all trauma-related injuries managed by deployed US military medical treatment facilities with surgical capabilities. We requested all documented prehospital care, which may have been delivered anywhere from the point-of-injury until a fixed-facility with surgical capabilities. We stratified subjects according to Centers for Disease Control age groupings: <1 year, 1-4 years, 5-9 years, 10-14 years, and 15-17 years. Results: Of the 3,493 pediatric encounters in the DODTR, 1,004 underwent military evacuation from the point of injury: 911 (90.7%) by standard medical evacuation platforms and 93 (9.3%) by nonstandard, improvised evacuation assets. Six hundred seventy-five of the 1004 pediatric trauma casualties were between 5 and 14 years of age. Over 75% were male, over 80% were in Afghanistan, and most were injured by explosives. Across all age groups, serious injuries to the head/neck and extremities were most common. Subjects transported by standard evacuation platforms underwent tourniquet application (12.2% vs 5.3%, p < 0.05) and intraosseous access (12.2% vs 4.3%; p = 0.02) more frequently than those on nonstandard platforms. Casualties evacuated by nonstandard platforms underwent airway adjunct emplacement more frequently those on standard evacuation assets (3.2% vs 0.3%; p = 0.01). IV access and opiate administration were the most commonly performed interventions on both standard and nonstandard assets. Subject survival to hospital discharge was 88.1% on standard platforms and 89.2% on nonstandard platforms (p = 0.75). Conclusions: Approximately 30% of pediatric trauma casualties in Afghanistan and Iraq underwent medical evacuation from the point of injury directly to a military treatment facility with surgical capabilities. Most of those children did not undergo the prehospital interventions studied. Future investigations evaluating pediatric medical evacuation and prehospital care, medical staffing, pediatric-specific training, and equipping of pediatric-specific materials may be beneficial.

Pediatric trauma mortality: an ecological analysis evaluating correlation between injury-related mortality and geographic access to trauma care in the United States in 2010

Background

Trauma is the leading cause of mortality in the pediatric population &gt;1 year. Analyzing relationships between pediatric trauma-related mortality and geographic access to trauma centers (among other social covariates) elucidates the importance of cost and care effective regionalization of designated trauma facilities.

Methods

Pediatric crude injury mortality in 49 United States served as a dependent variable and state population within 45 minutes of trauma centers acted as the independent variable in four linear regression models. Multivariate analyses were performed using previously identified demographics as covariates.

Results

There is a favorable inverse relation between pediatric access to trauma centers and pediatric trauma-related mortality. Though research shows care is best at pediatric trauma centers, access to Adult Level 1 or 2 trauma centers held the most predictive power over mortality. A 4-year college degree attainment proved to be the most influential covariate, with predictive powers greater than the proximity variable.

Conclusions

Increased access to adult or pediatric trauma facilities yields improved outcomes in pediatric trauma mortality. Implementation of qualified, designated trauma centers, with respect to regionalization, has the potential to further lower pediatric mortality. Additionally, the percentage of state populations holding 4-year degrees is a stronger predictor of mortality than proximity and warrants further investigation.

Association Between Insurance and Transfer of Injured Children From Emergency Departments

OBJECTIVES

To determine if injured children presenting to nondesignated trauma centers are more or less likely to be transferred relative to being admitted based on insurance status.

METHODS

We conducted a cross-sectional study by using the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample. Pediatric trauma patients receiving care in emergency departments (EDs) at nontrauma centers who were either admitted locally or transferred to another hospital were included. We performed logistic regression analysis adjusting for injury severity and other confounders and incorporated nationally representative weights to determine the association between insurance and transfer or admission.

RESULTS

Nine thousand four hundred and sixty-one ED pediatric trauma events at 386 nontrauma centers met inclusion criteria. EDs that treated a higher proportion of patients with Medicaid had higher odds of transfer relative to admission (odds ratio [OR]: 1.2 per 10% increase in Medicaid; 95% confidence interval [CI]: 1.1-1.4), resulting in overall higher odds of transfer among patients with Medicaid compared with patients with private insurance (OR: 1.3; 95% CI: 1.0-1.5). A patient's insurance status was not associated with different odds of transfer relative to admission within individual EDs after adjusting for the ED's proportion of patients with Medicaid (Medicaid OR: 1.0; 95% CI: 0.8-1.1).

CONCLUSIONS

Injured pediatric patients presenting to nondesignated trauma centers are slightly more likely to be transferred than admitted when the ED treats a higher proportion of Medicaid patients. In this study, ongoing concerns about inequities in the delivery of care among hospitals treating high proportions of children with Medicaid are reinforced.

Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes

INTRODUCTION

Timely hemorrhage control is paramount in trauma; however, a critical time interval from emergency department arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW.

METHODS

Data of adults (n = 309) with hypotension and GSW to the torso requiring immediate operation from January 2004 to September 2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring more than 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. Statistical significance was considered at p ≤ 0.05.

RESULTS

The study population was aged 32 ± 12 years, 92% were male, Injury Severity Score was 24 ± 15, systolic blood pressure was 81 ± 29 mm Hg, Glasgow Coma Scale score was 13 ± 4. Overall mortality was 27%. Mean time to operation was 19 ± 13 minutes. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared with those who arrived in 10 minutes or less (HR, 1.89; 95% CI, 1.10-3.26; p = 0.02); this was also true in the severely hypotensive patients with systolic blood pressure of 70 mm Hg or less (HR, 2.67; 95% CI, 0.97-7.34; p = 0.05). The time associated with a 50% cumulative mortality was 16 minutes.

CONCLUSIONS

Delay to the operating room of more than 10 minutes increases the risk of mortality by almost threefold in hypotensive patients with GSW. Protocols should be designed to shorten time in the emergency department. Further prospective observational studies are required to validate these findings.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Predictors of mortality in pediatric trauma: experiences of a level 1 trauma center and an assessment of the International Classification Injury Severity Score (ICISS)

OBJECTIVES

Injury severity scoring tools allow systematic comparison of outcomes in trauma research and quality improvement by indexing an expected mortality risk for certain injuries. This study investigated the predictive value of the empirically derived ICD9-derived Injury Severity Score (ICISS) compared to expert consensus-derived scoring systems for trauma mortality in a pediatric population.

METHODS

1935 consecutive trauma patients aged <18 years from 1/2000 to 12/2012 were reviewed. Mechanism of injury (MOI), Injury Severity Score (ISS), Revised Trauma Score (RTS), Trauma Score ISS (TRISS), and ICISS were compared using univariate and multivariate logistic regression analysis and receiver operator characteristic analysis.

RESULTS

The population was a median age of 11 ± 6 year, 70 % male, and 76 % blunt injury. Median ISS 13 ± 12 and overall mortality 3.5 %. Independent predictors of mortality were initial hematocrit [odds ratio (OR) 0.83 (0.73-0.95)], HCO3 [OR 0.82 (0.67-0.98)], Glasgow Coma Scale score [OR 0.75 (0.62-0.90)], and ISS [OR 1.10 (1.04-1.15)]. TRISS was superior to ICISS in predicting survival [area under receiver operator curve: 0.992 (0.982-1.000) vs 0.888 (0.838-0.938)].

CONCLUSIONS

ICISS was inferior to existing injury scoring tools at predicting mortality in pediatric trauma patients.

Paediatric trauma systems and their impact on the health outcomes of severely injured children: An integrative review

BACKGROUND

Injury is a leading cause of death and disability for children. Regionalised trauma systems have improved outcomes for severely injured adults, however the impact of adult orientated trauma systems on the outcomes of severely injured children remains unclear.

AIMS

This research aims to identify the impact of trauma systems on the health outcomes of children following severe injury.

METHODS

Integrative review with data sourced from Medline, Embase, CINAHL, Scopus and hand searched references. Abstracts were screened for inclusion/exclusion criteria with fifty nine articles appraised for quality, analysed and synthesised into 3 main categories.

RESULTS

The key findings from this review include: (1) a lack of consistency of prehospital and inhospital triage criteria for severely injured children leading to missed injuries, secondary transfer and poor utilisation of finite resources; (2) severely injured children treated at paediatric trauma centres had improved outcomes when compared to those treated at adult trauma centres, particularly younger children; (3) major causes of delays to secondary transfer are unnecessary imaging and failure to recognise the need for transfer; (4) a lack of functional or long term outcomes measurements identified in the literature.

CONCLUSIONS

Research designed to identify the best processes of care and describe the impacts of trauma systems on the long term health outcomes of severely injured children is required. Ideally all phases of care including prehospital, paediatric triage trauma criteria, hospital type and interfacility transfer should be included, focusing on timeliness and appropriateness of care. Outcome measures should include long term functional outcomes in addition to mortality.

Microcirculatory alterations during haemorrhagic shock and after resuscitation in a paediatric animal model

BACKGROUND

Haemorrhagic shock is frequent in paediatric trauma patients and after cardiac surgery, especially after cardiopulmonary bypass. It has demonstrated to be related to bad outcome.

OBJECTIVES

To evaluate changes on microcirculatory parameters during haemorrhagic shock and resuscitation in a paediatric animal model. To determine correlation between microcirculatory parameters and other variables routinely used in the monitoring of haemorrhagic shock.

METHODS

Experimental study on 17 Maryland pigs. Thirty minutes after haemorrhagic shock induction by controlled bleed animals were randomly assigned to three treatment groups receiving 0.9% normal saline, 5% albumin with 3% hypertonic saline, or 5% albumin with 3% hypertonic saline plus a bolus of terlipressin. Changes on microcirculation (perfused vessel density (PVD), microvascular blood flow (MFI) and heterogeneity index (HI)) were evaluated and compared with changes on macrocirculation and tisular perfusion parameters.

RESULTS

Shock altered microcirculation: PVD decreased from 13.5 to 12.3 mm mm(-2) (p=0.05), MFI decreased from 2.7 to 1.9 (p<0.001) and HI increased from 0.2 to 0.5 (p<0.001). After treatment, microcirculatory parameters returned to baseline (PVD 13.6 mm mm(-2) (p<0.05), MFI 2.6 (p<0.001) and HI 0.3 (p<0.05)). Microcirculatory parameters showed moderate correlation with other parameters of tissue perfusion. There were no differences between treatments.

CONCLUSIONS

Haemorrhagic shock causes important microcirculatory alterations, which are reversed after treatment. Microcirculation should be assessed during haemorrhagic shock providing additional information to guide resuscitation.