Paediatric trauma at an adult trauma centre

Paediatric trauma imaging in a regional Queensland hospital: Do we need clearer guidance?

OBJECTIVE

Paediatric trauma is a major cause of morbidity and mortality in those aged 0-14. Anatomical and physiological differences require a specialised approach to paediatric trauma care. Medical imaging, particularly computed tomography (CT) scans, requires specific consideration because of the consequences of radiation exposure in the paediatric population. The present study compares current practice of CT scan ordering in paediatric trauma patients at a regional Australian hospital against consensus guidelines published in the UK.

METHODS

A retrospective audit of paediatric trauma CT scans referred from the ED from May 2017 to May 2018 was completed. Details relating to CT scan ordering were reviewed and compliance with the Royal College of Radiologists Paediatric trauma protocols, was determined. Descriptive statistics and χ² tests comparing those that met and did not meet guidelines were performed.

RESULTS

A total of 71 CT scans were included with an overall compliance rate of 56.3%. Specific regional compliance was lowest with CT neck at 14%. Patients where a trauma call was initiated were more likely to receive a full body (pan) scan rather than region specific imaging. Compliance improved when paediatric team involvement was documented.

CONCLUSIONS

Evidence-based guidelines for CT imaging in paediatric trauma are essential to reduce unnecessary radiation exposure for children. The present study has demonstrated that current practice has the potential to be improved and that decisions should involve a multidisciplinary team.

Profile of Pediatric Trauma among the Patients Attending Emergency Department in a Tertiary Care Hospital in South India

Background

Pediatric trauma is emerging as an epidemic worldwide; the epidemiology of pediatric trauma is different in different parts of the world. There are very few studies describing the pediatric trauma in developing countries.

Objectives

The objectives of this study were to assess the type, mechanism, and extent of trauma among pediatric trauma patients and its association with clinical outcome.

Methodology

This was a prospective observational study conducted in the department of emergency medicine and trauma at a tertiary care hospital in South India from September 2015 to March 2017. All children aged <12 years with a history of injuries irrespective of the cause for attending our trauma center were included in the study.

Observations and Results

Of the 911 children enrolled, 63.9% sustained injuries at home. The leading modes of injury were fall at level ground (26.9%), road traffic accidents (RTAs) (25.5%), and fall from height (16.8%). Majority of RTA victims were two-wheeler pillion riders (40.5%) and pedestrians (31.9%). Nearly 49% of children had head and maxillofacial injuries. Polytrauma was found in 3.6% of children. Based on the Pediatric Trauma Score (PTS), 72.6% of children had mild trauma and 6.1% severe trauma. Totally, 18.9% of children required inpatient management, 7.5% surgical intervention, and 1.8% expired.

Conclusions

Most of injuries in children occurred at home. This was followed by injuries on road. The leading cause of polytrauma was RTA. RTA victims were more likely to have severe injuries and poor outcome. They were more likely to require inpatient management compared to those who fell from height or fell at level ground. Glasgow Coma Scale and PTS may be used reliably to assess the severity of injuries sustained by children.

A review of children with severe trauma admitted to pediatric intensive care in Queensland, Australia

Background

The aim of this study is to review patient characteristics, injury patterns, and outcomes of trauma cases admitted to pediatric intensive care in Children’s Health Queensland, Brisbane, Queensland, Australia.

Methods

Routinely recorded data collected prospectively from the Children’s Health Queensland Trauma Service registry from November 2008 to October 2015 were reviewed. Demographic and clinical characteristics of trauma cases in children under 16 years of age are described, and their association with age and mortality analyzed.

Results

There were 542 cases of pediatric trauma identified and 66.4% were male. The overall mortality since January 2012 was 11.1%. The median injury severity score (ISS) was 11 (IQR = 9–22), 48.2% (n = 261) had an ISS > 12 and 41.7% (n = 226) patients had an ISS > 15. The most common injury patterns were isolated head injury (29.7%; n = 161) and multiple trauma (31.2%; n = 169). In 28.4% of cases (n = 154) surgery was required. The home was reported to be the most common place of injury (37.6%; n = 204). Children aged 0–4 years were least likely to survive their injury (15.3% mortality) compared with the 5–9 (5.6% mortality) and 10–15 (9.0% mortality) age groups. Higher mortality was associated with more severe injuries, abdomen/spine/thorax injuries, inflicted injuries, drowning and hanging.

Conclusion

This description of major pediatric trauma cases admitted to pediatric intensive care in Children’s Health Queensland, Australia, will inform future pediatric major trauma service requirements as it identifies injury patterns and profiles, injury severity, management and mortality across different age groups.

Comparative analysis of trends in paediatric trauma outcomes in New South Wales, Australia

Paediatric trauma centres seek to optimise the care of injured children. Trends in state-wide paediatric care and outcomes have not been examined in detail in Australia. This study examines temporal trends in paediatric trauma outcomes and factors influencing survival and length of stay. A retrospective review was conducted using data from the NSW Trauma Registry during 2003-2008 for children aged 15 years and younger who were severely injured (injury severity score >15). To examine trauma outcomes descriptive statistics and multivariable logistic and linear regression were conducted. There were 1138 children severely injured. Two-thirds were male. Road trauma and falls were the most common injury mechanisms and over one-third of incidents occurred in the home. Forty-eight percent of violence-related injuries were experienced by infants aged less than 1 year. For the majority of children definitive care was provided at a paediatric trauma centre, but less than one-third of children were taken directly to a paediatric trauma centre post-injury. Children who received definitive treatment at a paediatric trauma centre had between 3 and 6 times higher odds of having a survival advantage than if treated at an adult trauma centre. The number of severe injury presentations to the 14 major trauma centres in NSW remains constant. It is possible that injury prevention measures are having a limited effect on severe injury in NSW. This research provides stimulus for change in the provision and co-ordination in the delivery of trauma care for injured children.

Investigating moderate to severe paediatric trauma in the Auckland region

OBJECTIVE

To investigate differences between paediatric patients with moderate to severe trauma admitted from two paediatric ED, with respect to: demographics, patterns of presentation, mechanism of injury, injury severity scores (ISS), interventions and outcome.

METHOD

Retrospective cohort study. Moderate to severe trauma was defined as ISS>9. Paediatric patients admitted to hospital via Starship Children's Emergency or KidzFirst ED, with trauma from 1 May 2003 to 30 April 2004, with ISS>9 were identified using multiple databases. The charts were reviewed and data collected included: demographics, hospital of first presentation, diagnoses, ISS, Paediatric trauma score (PTS), Glasgow coma score (GCS), ventilator hours, length of admission, survival and discharge destination. Descriptive statistics with 95% confidence intervals, Mann-Whitney U-test, chi2-test and Fisher's exact test were used as appropriate.

RESULTS

A total of 393 children with moderate to severe trauma were identified using initial search strategies. Of these, 82 children met the inclusion and exclusion criteria for the study; 42 children were admitted via KidzFirst ED and 40 via Starship Children's ED. There was no statistically significant difference in ISS (P=0.86), PTS (P=0.11), GCS (P=0.62), hours on a ventilator (P=0.28) and length of stay (P=0.87) between children admitted from Starship or KidzFirst ED.

CONCLUSION

This study suggests that there are no differences in the numbers or severity of paediatric trauma patients admitted from the Starship and KidzFirst ED. This indicates triage is to the closest ED despite having a tertiary referral centre for paediatric trauma available in Auckland City.

Specialty coverage at non-tertiary care centers

The fundamental tenet of a trauma system is to get the right patient to the right hospital at the right time. Although most injuries are minor or moderate and can be managed at local community hospitals, a significant minority of injured patients require extensive and expensive care to survive or minimize injury. Most prehospital trauma triage criteria address a combination of factors to consider, but this approach sometimes fails to identify patients with severe injuries and often burdens trauma centers with patients suffering minor injuries. It is critical to utilize a method to differentiate those injury victims who need the specialized expertise and resources available in trauma centers from those who can be adequately cared for locally. Although trauma centers assume the leadership role, in a truly inclusive system, all health care providers (prehospital, community hospitals, and trauma centers) have a defined role in providing care to patients with trauma. All these institutions should establish and maintain transfer agreements for the transfer of patients meeting system trauma triage criteria. Because prehospital triage criteria are not 100% sensitive, there should be a mechanism in place for the secondary triage of patients. Initial management of patients should continue while efforts are made to transfer the patient.