Childhood falls: characteristics, outcome, and comparison of the Injury Severity Score and New Injury Severity Score

Are challenging walking environments linked to falls or risk of falling in children with cerebral palsy? A systematic review

BACKGROUND

Children with cerebral palsy (CP) regularly fall over and this has negative effects on their physical and psychosocial wellbeing (e.g., reduced activity participation). However, the reasons for falls are not well understood. The way in which children negotiate challenging walking environments (e.g., uneven surfaces), may reveal more about how falls occur as these environments require gait modifications to maintain stability. Stability in challenging walking environments has been explored for children with CP; however, it remains unclear how these lead to falls.

RESEARCH QUESTION

Do challenging walking environments that mimic those faced in the real-world, contribute to increased fall occurrence and fall risk in children with CP?

METHODS

Five databases were searched, and 1386 records screened to include ambulatory children with CP, aged 5-18 years old, investigating dynamic walking in challenging environments, with outcomes of fall occurrence or fall risk. The full protocol for this review was registered on PROSPERO (CRD42021290456).

RESULTS

Sixteen studies met the inclusion criteria. One study reported occurrence of stumbles, two reported no falls. Fifteen studies identified gait alterations used by children with CP in challenging environments. Twenty-four gait characteristics were identified to be indicative of cautious walking strategies and seven gait characteristics identified to increase fall risk, suggesting a potential link. However, limited evidence exists as to whether this reflects falls faced in the real-world.

SIGNIFICANCE

Investigations into stability over challenging walking environments for children with CP are lacking any measures of fall occurrence. Investigations into the mechanisms that may contribute to high fall risk, or fall avoidance when negotiating obstacles, uneven surfaces, steep declines and stairs may reveal further causes of real-world falls, and in doing so inform future fall prevention techniques. Finally, understanding the multifaceted causes of falls in real-world challenging environments from the perspectives of children with CP is key for future research.

The paediatric polytrauma CT-indication (PePCI)-score-Development of a prognostic model to reduce unnecessary CT scans in paediatric trauma patients

BACKGROUND

Whole-Body CT (WBCT) is frequently used in emergency situations for promptly diagnosing paediatric polytrauma patients, given the challenges associated with obtaining precise details about the mechanism and progression of trauma. However, WBCT does not lead to reduced mortality in paediatric patients, but is associated with high radiation exposure. We therefore wanted to develop a screening tool for CT demand-driven emergency room (ER)-trauma diagnostic to reduce radiation exposure in paediatric patients.

METHODS

A retrospective study in a Level I trauma centre in Germany was performed. Data from 344 paediatric emergency patients with critical mechanism of injury who were pre-announced by the ambulance for the trauma room were collected. Patients' symptoms, clinical examination, extended Focused Assessment with Sonography for Trauma (eFAST), routinely, laboratory tests and blood gas and - when obtained - WBCT images were analysed. To identify potential predictors of severe injuries (ISS > 23), 300 of the 344 cases with complete data were subjected to regression analyses model.

RESULTS

Multiple regression analysis identified cGCS, base excess (BE), medically abnormal results from eFAST screening, initial unconsciousness, and injuries involving three or more body regions as significant predictors for a screening tool for decision-making to perform WBCT or selective CT. The developed Paediatric polytrauma CT-Indication (PePCI)-Score was divided into three risk categories and achieved a sensitivity of 87 % and a specificity of 71 % when comparing the low and medium risk groups with the high risk group. Comparing only the low-risk group with the high-risk group for the decision to perform WBCT, 32/35 (91 %) of patients with an ISS >23 were correctly identified, as were 124/137 (91 %) with lower ISS scores.

CONCLUSION

With the newly developed PePCI-Score, the frequency of WBCT in a paediatric emergency patients collective can be significantly reduced according to our data. After prospective validation, the initial assessment of paediatric trauma patients in the future could be made not only by the mechanism of injury, but also by the new PePCI-Score, deriving on clinical findings after thorough clinical assessment and the discretion of the trauma team.

Falls from height in children: epidemiology and outcome

INTRODUCTION

Childhood injury is one of the leading causes of death globally, with falls being the sixth leading cause. This study aimed to examine the demographics, patterns of injury and temporal risk factors for falls from height above 3 m in Singapore.

METHODS

This is a retrospective study conducted on patients who presented after a fall to a paediatric emergency department at a tertiary hospital between January 2011 and July 2017. Electronic medical records were reviewed to extract demographics and data on the patterns of injuries. Criteria for inclusion were patients under 18 years of age and the occurrence of fall from a height of 3 m or above.

RESULTS

A total of 149 children met the inclusion criteria. The median age was 10 years and 69.1% were boys. Death occurred in two (1.3%) cases; 84 (56.4%) were admitted and survived. Of those admitted, five (3.4%) required care in the intensive care unit and 11 (7.4%) required surgery. Falls occurred mostly at homes or residential buildings (n = 59, 39.6%). The two cases of mortality were due to falls from windows at homes. Twenty (33.9%) children fell from windows at homes, with two requiring admission to the intensive care unit.

CONCLUSION

Our study shows that falls from windows of homes are an important cause of mortality. Height of fall was also an important predictor of morbidity that led to a higher level of hospitalisation care. Preventive measures should be implemented to ensure safety in high-rise residential buildings to prevent paediatric falls from heights.

The effect of birth order on length of hospitalization for pediatric traumatic brain injury: an analysis of the 1987 Finnish birth cohort

Purpose

This study examines the relationship between birth order and length of hospitalization due to pediatric traumatic brain injury (TBI).

Methods

We prospectively followed 59,469 Finnish newborns from 1987 until age 18 years. Data on first diagnosis of TBI was recorded within the 1987 Finnish Birth Cohort (FBC). Hospitalization period was divided into two categories: 2 days or less and more than 2 days. The latter was considered in this study as longer hospitalization.

Results

Compared with first born siblings, later born siblings had an increased risk of a longer hospitalization for TBI (12.7% of fourth or higher born birth children diagnosed with TBI were hospitalized for 2 or more days, 11.3% of first born, 10.4% of third born and 9.0% of second born). Fourth or higher born children were more likely to experience a repeat TBI; 13.4% of fourth or higher born children diagnosed with TBI had 2–3 TBIs during the study period compared to 9% of third born, 7.8% of second born and 8.8% of the first born. Injuries in the traffic environment and falls were the most common contributors to pediatric TBI and occurred most frequently in the fourth or higher birth category; 29.3% of TBIs among fourth or higher birth order were due to transport accidents and 21% were due to falls.

Conclusions

This study revealed a significant increase in risk for longer hospitalization due to TBI among later born children within the same sibling group. The study provides epidemiological evidence on birth order as it relates to TBI, and its potential to help to explain some of the statistical variability in pediatric TBI hospitalization over time in this population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00919-x.

Bunk-Bed-Related Fractures in Children: Are We Aware of the Risks?

Background and Objectives: Falls from heights are a common mechanism of trauma in children. However, data on bunk-bed-related (BBR) fractures are scarce. We aimed to assess types of fractures and age groups most at risk for BBR fractures. Material and Methods: We analyzed medical records and imaging procedures of patients aged <18 years who sustained a bunk bed injury and were treated at our department between January 2014 and December 2021. Demographic data, including age groups, mechanisms, types and anatomical regions of fractures, were assessed. Results: A total of 162 patients (median age 5 years, range 0−15; 59.9% male) was included. Fractures were recorded in 80 (49.4%) and contusions and abrasions in 49 (30.2%) cases. BBR fractures were recorded in 44.8% of children below the age of 3, in 50.8% aged 3−5, in 58.5% aged 6−9 and in 28.6% ≥ 10 years. Forearm fractures were most common (n = 34, 42.5%), followed by fractures of the clavicle (n = 13, 16.3%), humerus (n = 10, 12.5%), foot (n = 8, 10.0%), hand (n = 5, 6.3%), lower leg (n = 5, 6.3%) and skull (n = 5, 6.3%). Surgery was required in 12 (15.0%) cases, including closed reduction (n = 7) and closed reduction with internal fixation (n = 5). Overall, 21 (26.3%) patients were hospitalized with a mean length of stay of 2 ± 1.6 days. Conclusions: Caregivers should be aware that bunk beds cause a significant amount of severe trauma in children and adolescents, especially in those younger than 10 years of age. Caregivers would benefit from receiving information about these risks and evidence-based strategies to prevent BBR fractures.

Predictors of 12 month functional outcomes and length of stay of severely injured children in NSW, Australia. A longitudinal multi-centre study

BACKGROUND

The majority of paediatric injury outcomes studies focus on mortality rather than the impact on long-term quality of life, health care use and other health-related outcomes. This study sought to determine predictors of 12-month functional and psychosocial outcomes for children sustaining major injury in NSW.

METHODS

The study included all children < 16 years requiring intensive care or an injury severity score (ISS) ≥ 9 treated in NSW at a paediatric trauma centre (PTC). Children were identified through the three PTCs and NSW Trauma Registry. The paediatric Quality of Life Inventory (PedsQL) and EuroQol five-dimensional EQ-5D-Y were used to measure HRQoL post-injury, completed via parent/carer proxy recruited through NSW PTCs.

RESULTS

There were 510 children treated at the three NSW PTCs during the 15-month study period. The mean (SD) age was 6.7 (6.0) years, with a median NISS (New Injury Severity Score) of 11 (IQR: 9-18). Regression analysis showed worse psychosocial health at twelve months was associated with hospital length of stay (LoS) and number of body regions injured (F₂,₆₅ = 5.85, p = 0.005). Physical outcome was associated with LoS and intensive care unit (ICU) admission (F_2,66 = 13.48, p < 0.001). Hospital LoS was significantly associated with NISS and head injury (F_2,398 = 51.5, p < 0.001).

CONCLUSION

Hospital length of stay and polytrauma are independent factors that negatively influence psychological and physical outcomes of children with major injuries. Early intervention to enable emotional well-being, discharge home and long-term follow up such as dedicated family support and rehabilitation at home could reduce preventable poor outcomes.

Settling the Score: Injury Severity Score Fails to Capture Nuances in Pediatric Trauma

OBJECTIVES

Recent work has questioned the accuracy of the Injury Severity Score (ISS) and the Abbreviated Injury Scale (AIS) in the pediatric population. We sought to determine mortality rates in pediatric trauma patients at ISSs considered "severe" in adults and whether mortality would vary substantially between adults and children sustaining injuries with the same AIS.

METHODS

Univariate logistic regression was used to generate mortality rates associated with ISS scores, for children (<16 years of age) and adults, using the 2016 National Trauma Data Bank. Mortality rates at an ISS of 15 were calculated in both groups. We similarly calculated ISS scores associated with mortality rates of 10%, 25%, and 50%. Receiver operating characteristic curves were constructed to compare the discriminative ability of ISS to predict mortality after blunt and penetrating injuries in adults and children. Mortality rates associated with 1 or more AIS 3 injuries per body region were defined.

RESULTS

There were 855,454 cases, 86,414 (10.1%) of which were children. The ISS associated with 10%, 25%, and 50% mortality were 35, 44, and 53, respectively, in children; they were 27, 38, and 48 in adults. At an ISS of 15, pediatric mortality was 1.0%; in adults, it was 3.1%. A 3.1% mortality rate was not observed in children until an ISS of 25. On receiver operating characteristic analysis, the ISS performed better in children compared with adults (area under the curve, 0.965 vs 0.860 [P < 0.001]). Adults consistently suffered from higher mortality rates than did children with the same number of severe injuries to a body region, and mortality varied widely between specific selected AIS 3 injuries.

CONCLUSIONS

Although the ISS predicts mortality well, children have lower mortality than do adults for the same ISS, and therefore, the accepted definition of severe injury is not equivalent between these 2 cohorts. Mortality risk is highly dependent on the specific nature of the injury, with large variability in outcomes despite identical AIS scores.

Analysis of Unintentional Falls in Pediatric Population and Predictors of Morbidity

INTRODUCTION

Unintentional falls are a leading cause of pediatric traumatic injury. This study evaluates clinical outcomes of fall-related injuries in children under the age of 10.

METHODS

The National Trauma Database was queried for children who experienced an unintentional fall. Patients were stratified by age in two groups: 1-5 and 6-10 years old. The primary outcome was post discharge extension of care, defined as transfer to skilled nursing facility or rehabilitation center after discharge from the hospital. Descriptive statistics and a multivariable logistic regression analysis were used to compare the two groups.

RESULTS

From 2009 to 2016, a total of 8,277 pediatric patients experienced an unintentional fall, with 93.6% of patients being discharged home. Falls were more common in younger children, with greater odds of post discharge extension of care. Predictors of increased associated risk of extended medical care included intracranial hemorrhage (OR 1.05, 95% CI 1.03-1.06) and thoracic injuries (OR 1.03, 95% CI 1.00-1.1.05) (P< 0.05). Mortality in pediatric patients suffering unintentional falls was a rare event occurring in 0.7% of cases in children 1-5 years old and 0.4% of children 6-10 years old.

CONCLUSION

The majority of children experiencing an unintentional fall are discharged home, with mortality being very rare. However, younger age is prone to more severe and serious injury patterns. Intracranial hemorrhage and thoracic injury were a predictor of need for extended medical care.

Pattern and risk factors for childhood injuries in Dar es Salaam, Tanzania

Background

Injuries contribute to morbidity and mortality in children. This study was carried out to describe the pattern of childhood injuries and associated risk factors in Dar es Salaam, Tanzania.

Methods

This case control study was conducted in six selected health facilities in Dar es Salaam, Tanzania. Data were collected using a structured questionnaire. Cases and controls were children below 18 years who had suffered injuries and those without injury associated condition respectively.

Results

A total of 492 cases and 492 controls were included in the study, falls (32%), burns (26%), Road Traffic Injuries (14%) and cuts (10%) were the major types of injuries identified. Younger parents/guardians {Adjusted odds ratio (AOR)= 1.4; 95% CI: 1.4 -3.6}, more than six people in the same house (AOR= 1.8; 95% CI: 1.3–2.6), more than three children in the house {AOR= 1.4; 95% CI (1.0–2.0)}, absence of parent/guardian at time of injury occurrence (AOR= 1.6; 95% CI: 1.1–2.3), middle socio-economic (AOR=1.6; 95%CI: 1.1–2.4) and low socio-economic status (AOR= 1.5; 95% CI: 1.0–2.1) were independent risk factors for childhood injury.

Conclusion

Falls, burns and road traffic injuries were the main injury types in this study. Inadequate supervision, overcrowding, lower socio-economic status and low maternal age were significant risk factors for childhood injuries.

Unintentional falls among children in rural Ghana and associated factors: a cluster-randomized, population-based household survey

INTRODUCTION

falls contribute to almost one-fifth of injury-related deaths. The majority of these occur in low- and middle-income countries. The impact of fall injury in low- and middle-income countries is greater in younger individuals. We aimed to determine the epidemiology of falls among rural Ghanaian children.

METHODS

from March to May, 2018, we conducted a cluster-randomized household survey of caregivers in a rural Ghanaian sub-district, regarding household child falls and their severity. We utilized a previously validated survey tool for household child injury. Associations between household child falls and previously described predictors of household child injury were examined with multivariable logistic regression. These included age and gender of the child, household socioeconomic status, caregiver education, employment status, and their beliefs on why household child injuries occur.

RESULTS

three hundred and fifty-seven caregivers of 1,016 children were surveyed. One hundred and sixty-four children under 18 years had sustained a household fall within the past six months, giving a household child fall prevalence of 16% (95% C.I, 14%-19%). Mean age was 4.4 years; 59% were males. Ground level falls were more common (80%). Severity was mostly moderate (86%). Most caregivers believed household child injuries occurred due to lack of supervision (85%) or unsafe environment (75%); only 2% believed it occurred because of fate. Girls had reduced odds of household falls (adjusted O.R 0.6; 95% C.I 0.4-0.9). Five to nine year-old and 15-17 year-old children had reduced odds of household falls (adjusted O.R 0.4; 95% C.I 0.2-0.7 and 0.1; 95% C.I 0.02-0.3, respectively) compared to 1-4 year-olds. Caregiver engagement in non-salary paying work was associated with increased odds of household child falls (adjusted O.R 2.2; 95% C.I 1.0-4.7) compared to unemployed caregivers. There was no association between household child falls and caregiver education, socioeconomic status and beliefs about why household child injuries occurred.

CONCLUSION

the prevalence of household child falls in rural Ghana was 16%. This study confirms the need to improve supervision of all children to reduce household falls, especially younger children and particularly boys. Majority of caregivers also acknowledge the role of improper child supervision and unsafe environments in household child falls. These beliefs should be reinforced and emphasized in campaigns to prevent household child falls in rural communities.

Fear in infancy: Lessons from snakes, spiders, heights, and strangers

This review challenges the traditional interpretation of infants' and young children's responses to three types of potentially "fear-inducing" stimuli-snakes and spiders, heights, and strangers. The traditional account is that these stimuli are the objects of infants' earliest developing fears. We present evidence against the traditional account, and provide an alternative explanation of infants' behaviors toward each stimulus. Specifically, we propose that behaviors typically interpreted as "fearful" really reflect an array of stimulus-specific responses that are highly dependent on context, learning, and the perceptual features of the stimuli. We speculate about why researchers so commonly misinterpret these behaviors, and conclude with future directions for studying the development of fear in infants and young children. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Where to start? Injury prevention priority scores in Canadian children

PURPOSE

Given limited resources, it is essential to determine which Mechanisms of Injury (MOIs) to prioritize for injury prevention policy and research. We developed objective, evidence-based Injury Prevention Priority Scores (IPPSs) for Canadian children across three prevention perspectives: mortality, injury severity, and resource utilization.

METHODS

We performed a retrospective cohort study of all injuries in Canada in individuals aged 0 to 19 years old from 2009 to 2014. For each MOI, an IPPS was calculated as a balanced measure of frequency and either mortality rate, median ICD-10 derived Injury Severity Score (ICISS), or median cost per hospitalization.

RESULTS

Of 87,017 injuries, 83,112 were nonfatal hospitalizations, and 3905 were deaths. Overall mortality rate was 0.04 deaths/injury, median ICISS was 0.994 (IQR 0.75-0.996), and median cost per hospitalization was CAD$3262 (IQR $2118-$5001). The top three mechanisms were falls (IPPS 72), intentional self-harm (IPPS 68), and drowning (IPPS 65) for mortality, falls (IPPS73), drowning (IPPS 61), and suffocation (IPPS 61) for injury severity and falls (IPPS 70), fires (IPPS 65), and intentional self-harm (IPPS 60) for resource utilization.

CONCLUSION

Falls, if prevented, would provide the most benefit to the largest proportion of the Canadian pediatric population and should be targeted for injury prevention.

LEVEL OF EVIDENCE

Level III.

Social Determinants of Health and Home Safety for Under-five Children in a Neighbor's Tehran, Iran

Background:

Social determinants of health (SDH) provide a platform in improving health society such as safety. Safety is essential for children because it is directly related to the health and development. The objective of this study was to evaluate the current home safety in the capital city of Iran for children below five years by community-based initiative and its association with common SDH variables.

Methods:

This is a cross-sectional study, considering community- and family-based initiative. According this five domains checklist which was including physical, kitchen, bath, toys, and first-aid kit, 200 family home safety were evaluated. Moreover, the relation between children safety and social determinants of health was assessed. Furthermore, the research team designed an attractive record card for each child that was distributed among families by community volunteers.

Results:

The result was extracted into two age groups: less and more than 6 months. We designed an attractive card for each child and distributed among families by volunteers. It showed that children of age above 6 months had higher home safety score. We found a positive association between mother's education and total safety score.

Conclusions:

This study was a part of MAZDAK project which means friendly environment for children in Persian word. It showed that an effective way for promoting children safety in the community would be community engagement and family cooperation. As the family education can help reduce children injuries, MAZDAK as a model can been run in the other places to check the effects of SDH on home safety for children. This was an experience of improving community knowledge and behavior about home safety by the parents themselves to improve their children safety environment, and it is going to continue the efficacy of Intervention.

Characterization of fall patients: Does age matter?

INTRODUCTION

Evaluating age-specific fall characteristics is important for prevention programs. The aim was to characterize fallers who presented to our trauma center. We hypothesized that fall characteristics and outcomes would vary with age.

METHODS

Data were retrospectively collected from the trauma registry and electronic medical records during January 1st, 2014-December 31st, 2015. Data were analyzed by Chi-square test with Yates' continuity correction and one-way ANOVA with Bonferroni's multiple comparisons test.

RESULTS

There were 1541 fallers, 814 (52.8%) were male. Ages ranged from 11 months to 100years. The admission rate was high at 86%, with an average hospital stay of 5.7days. Patients in the 0-18 and 19-45age groups spent significantly less time in the hospital (p<0.0001). Elderly patients had the highest average injury severity score (p<0.0001). However, the youngest patients required surgery more often (p=0.0004). The overall mortality rate was 3.6% and 52.8% were male. The mortality rate increased with age, from 0% for the 0-18 age group to 6.9% for patients ≥65years of age. Remarkably, fallers in the 19-45 and 46-64age groups predominantly died from ground level falls even though the average fall height in these groups was the highest (p<0.0001). More fallers in the 19-45 and 46-64age groups tested positive for alcohol/drug use (p<0.0001). Middle-aged and elderly patients were more likely to be discharged to a skilled nursing or rehabilitation facility compared to younger patients who were discharged home.

CONCLUSIONS AND PRACTICAL APPLICATIONS

Fall characteristics and outcomes varied with age. Data on age-specific characteristics, outcomes, and risk factors of falls will help in developing targeted interventions and may lead to better approaches to treat patients.

A Changing of the Abbreviated Injury Scale that Improves Accuracy and Simplifies Scoring

Objective

We present here a changing of the abbreviated injury scale (AIS). It is called the changed injury severity score (CISS), and significantly outperforms the venerable but dated the injury severity score (ISS) and the new injury severity score (NISS) as a predictor of mortality.

Methods

The CISS is defined as a change of AIS values by raising each AIS severity score (1-6) by a power of 4.12 divided by 30.33 and then summing the three most severe (i.e. highest AIS) regardless of body regions. CISS values were calculated for every patient in two large independent data sets: 3455, 3900 patients treated during a five-year period at the class A grade III comprehensive hospitals in Affiliated Hospital of Hangzhou Normal University (Hangzhou) and Zhejiang Provincial People's Hospital (Zhejiang). The power of CISS to predict morality was then compared with previously calculated NISS values of the same group patients in the two hospitals.

Results

We found CISS was more accurate than NISS to predict the survival. The receiver operating characteristic (ROC) of NISS and CISS in Hangzhou were 0.919 and 0.937 respectively (p=0.026), whereas for Zhejiang were 0.917 and 0.940 respectively (p=0.022). Moreover, CISS provided a better fit throughout its entire range of prediction. Hosmer-Lemeshow (H-L) statistic for NISS and CISS in Hangzhou were 24.00 (p=0.002) and 19.38 (p=0.007), whereas in Zhejiang were 22.70 (p=0.001) and 18.43 (p=0.005) respectively.

Conclusions

CISS is a modified version of NISS/ISS with better statistical property and can be considered in trauma research.

Evaluation of the Revised Trauma Score in Predicting Outcomes of Trauma Patients

Introduction

The revised trauma score (RTS) was developed more than 20 years ago. Few studies investigated its usefulness in predicting trauma outcomes. This is especially true for the weighted version of RTS (RTS-w). The aim of this study was to test the predicting power of RTS-w for the trauma outcomes including mortality, admission to intensive care unit (ICU), hospital length of stay and ICU length of stay through a comparison with Injury Severity Score (ISS).

Methods

Descriptive data, variables related to the trauma scores and outcomes were collected. The statistical performance of RTS-w and ISS in predicting the trauma outcomes using receiver operating characteristics (ROC) curves and the area under the curve (AUC) with 95% confidence interval and p value were calculated. The Hosmer-Lemeshow chi-squared statistic was performed to measure its calibration.

Results

A total of 3323 patients were enrolled in the study. RTS-w was significantly better than ISS in predicting mortality of trauma patients (AUC: 0.934 vs.0.880, p<0.0001). However, for the other three outcomes, i.e. admission to ICU, hospital length of stay and intensive care unit length of stay, the performance of RTS-w was inferior to ISS.

Conclusions

The RTS-w is a better predictor of mortality than ISS. But its ability to predict other trauma outcomes is not as good as ISS. More studies are needed to identify the predictive ability of RTS-w for the outcomes other than mortality. Besides, updating the coefficients of the formula may make RTS-w more accurate.

Predicting mortality, hospital length of stay and need for surgery in pediatric trauma patients

PURPOSE

Pediatric trauma is one of the major health problems around the world which threats the life of children. The survival of injured children depends upon appropriate care, accurate triage and effective emergent surgery. The objective of this study was to determine the predictive values of injury severity score (ISS), new injury severity score (NISS) and revised trauma score (RTS) on children's mortality, hospitalization and need for surgery.

METHODS

In this study, records of trauma patients under 15 years old transported from a trauma scene to emergency department of Poursina hospital from 2010 to 2011 were included. Statistical analysis was applied to determine the ISS, NISS and RTS ability in predicting the outcomes of interest.

RESULTS

There were 588 records in hospital registry system. The mean age of the patients was (7.3 ± 3.8) years, and 62.1% (n = 365) of patients were male. RTS was the more ability score to predict mortality with an area under curve (AUC) of 0.99 (95% CI, 0.99-1). In the hospital length of stay (LOS), ISS was best predictor for both the hospital LOS with AUC of 0.72 (95% CI, 0.67-0.76) and need for surgical surgery with AUC of 0.94 (95% CI, 0.90-0.98).

CONCLUSION

RTS as a physiological scoring system has a higher predicting AUC value in predicting mortality. The anatomic scoring systems of ISS and NISS have good performance in predicting of hospital LOS and need for surgery outcomes.

Comparison of the new Exponential Injury Severity Score with the Injury Severity Score and the New Injury Severity Score in trauma patients: A cross-sectional study

Objective

To compare Exponential Injury Severity Score (EISS) with Injury Severity Score (ISS) and New Injury Severity Score (NISS) in terms of their predictive capability of the outcomes and medical expenses of hospitalized adult trauma patients.

Setting

This study was based at a level I trauma center in Taiwan.

Methods

Data for 17,855 adult patients hospitalized from January 1, 2009 to December 31, 2015 were retrieved from the Trauma Registry System. The primary outcome was in-hospital mortality. Secondary outcomes were the hospital length of stay (LOS), intensive care unit (ICU) admission rate, ICU LOS, and medical expenses. Chi-square tests were used for categorical variables to determine the significance of the associations between the predictor and outcome variables. Student t-tests were applied to analyze normally distributed data for continuous variables, while Mann-Whitney U tests were used to compare non-normally distributed data.

Results

According to the survival rate-to-severity score relationship curve, we grouped all adult trauma patients based on EISS scores of ≥ 27, 9–26, and < 9. Significantly higher mortality rates were noted in patients with EISS ≥ 27 and those with EISS of 9–26 when compared to patients with EISS < 9; this finding concurred to the findings for groups classified by the ISS and NISS with the cut-off points set between 25 and 16. The hospital LOS, ICU admission rates, and medical expenses for patients with EISS ≥ 27 and patients with EISS of 9–26 were also significantly longer and higher than that of patients with EISS < 9. When comparing the demographics and detailed medical expenses of very severely injured adult trauma patients classified according to ISS, NISS, and EISS, patients with ISS ≥ 25 and NISS ≥ 25 both had significantly lower mortality rates, lower ICU admission rates, and shorter ICU LOS compared to patients with EISS ≥ 27.

Conclusions

EISS 9 and 27 can serve as two cut-off points regarding injury severity, and patients with EISS ≥ 27 have the greatest injury severity. Additionally, these patients have the highest mortality rate, the highest ICU admission rate, and the longest ICU LOS compared to those with ISS ≥ 25 and NISS ≥ 25, suggesting that patients with EISS ≥ 27 have the worst outcome.

Fall-related attendance and associated hospitalisation of children and adolescents in Hong Kong: a 12-year retrospective study

OBJECTIVES

The present study aimed to examine the trends and characteristics of fall-related attendance in accident and emergency department (AED) by injury type and the trend in associated average length of stay (LOS) among children and adolescents in Hong Kong.

DESIGN

A retrospective approach was adopted.

SETTING

AED, involving all local public emergency departments from 2001 to 2012.

PARTICIPANTS

63 557 subjects aged 0-19 years with fall injury record were included in the analysis.

PRIMARY OUTCOME MEASURES

Fall-related injury number and rates were calculated and reported. Poisson and negative binomial regression models were used to study the trends of injury incidence rate at different body regions.

RESULTS

AED fall-related attendance rate increased significantly with an annual percentage change of 4.45 (95% CI 3.43 to 5.47%, p<0.0001). The attendance number of male subjects was persistently higher than female subjects. The standardised rate of fracture injury increased by 1.31% (95% CI 0.56 to 2.05%, p<0.0001) and that of non-fracture injury increased by 9.23% (95% CI 7.07 to 11.43%, p<0.0001) annually. Upper limb was the most frequently fractured location. It included forearm/elbow, shoulder/upper arm and wrist/hand with descending order of frequency. On the contrary, head was the most frequent non-fracture location, followed by forearm/elbow.

CONCLUSIONS

The rates of fall-related attendance have been increasing and still remain high. There were significant increases in non-fracture injuries. Fractures were most frequently found in the upper extremity of a child while the most common non-fracture location was head. It appears that more efforts should be made and preventive measures should be implemented for children and adolescents in Hong Kong.

Comparison of the Ability to Predict Mortality between the Injury Severity Score and the New Injury Severity Score: A Meta-Analysis

Background: Description of the anatomical severity of injuries in trauma patients is important. While the Injury Severity Score has been regarded as the “gold standard” since its creation, several studies have indicated that the New Injury Severity Score is better. Therefore, we aimed to systematically evaluate and compare the accuracy of the Injury Severity Score and the New Injury Severity Score in predicting mortality. Methods: Two researchers independently searched the PubMed, Embase, and Web of Science databases and included studies from which the exact number of true-positive, false-positive, false-negative, and true-negative results could be extracted. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies checklist criteria. The meta-analysis was performed using Meta-DiSc. Meta-regression, subgroup analyses, and sensitivity analyses were conducted to determine the source(s) of heterogeneity and factor(s) affecting the accuracy of the New Injury Severity Score and the Injury Severity Score in predicting mortality. Results: The heterogeneity of the 11 relevant studies (total n = 11,866) was high (I² > 80%). The meta-analysis using a random-effects model resulted in sensitivity of 0.64, specificity of 0.93, positive likelihood ratio of 5.11, negative likelihood ratio of 0.27, diagnostic odds ratio of 27.75, and area under the summary receiver operator characteristic curve of 0.9009 for the Injury Severity Score; and sensitivity of 0.71, specificity of 0.87, positive likelihood ratio of 5.22, negative likelihood ratio of 0.20, diagnostic odds ratio of 24.74, and area under the summary receiver operating characteristic curve of 0.9095 for the New Injury Severity Score. Conclusion: The New Injury Severity Score and the Injury Severity Score have similar abilities in predicting mortality. Further research is required to determine the appropriate use of the Injury Severity Score or the New Injury Severity Score based on specific patient condition and trauma type.

Mechanisms, patterns and outcomes of paediatric polytrauma in a UK major trauma centre

Introduction Paediatric trauma is a significant burden to healthcare worldwide and accounts for a large proportion of deaths in the UK. Methods This retrospective study examined the epidemiological data from a major trauma centre in the UK between January 2012 and December 2014, reviewing all cases of moderate to severe trauma in children. Patients were included if aged ≤16 years and if they had an abbreviated injury scale score of ≥2 in one or more body region. Results A total of 213 patients were included in the study, with a mean age of 7.8 years (standard deviation [SD]: 5.2 years). The most common cause of injury was vehicle related incidents (46%). The median length of hospital stay was 5 days (interquartile range [IQR]: 4-10 days). Approximately half (52%) of the patients had to stay in the intensive care unit, for a median of 1 day (IQR: 0-2 days). The mortality rate was 6.6%. The mean injury severity score was 19 (SD: 10). Pearson's correlation coefficient showed a positive correlation for injury severity score with length of stay in hospital (p<0.001). Conclusions There is significant variation in mechanism of injury, severity and pattern of paediatric trauma across age groups. A multidisciplinary team approach is imperative, and patients should be managed in specialist centres to optimise their care and eventual functional recovery. Head injury remained the most common, with significant mortality in all age groups. Rib fractures and pelvic fractures should be considered a marker for the severity of injury, and should alert doctors to look for other associated injuries.

Tangent function transformation of the Abbreviated Injury Scale improves accuracy and simplifies scoring

INTRODUCTION

The Injury Severity Score (ISS) and the New Injury Severity Score (NISS) are widely used for anatomic severity assessments after trauma. We present here the Tangent Injury Severity Score (TISS), which transforms the Abbreviated Injury Scale (AIS) as a predictor of mortality.

MATERIAL AND METHODS

The TISS is defined as the sum of the tangent function of AIS/6 to the power 3.04 multiplied by 18.67 of a patient's three most severe AIS injuries regardless of body regions. TISS values were calculated for every patient in two large independent data sets: 3,908 and 4,171 patients treated during a 6-year period at level-3 first-class comprehensive hospitals: the Affiliated Hospital of Hangzhou Normal University and Fengtian Hospital Affiliated to Shenyang Medical College, China. The power of TISS to predict mortality was compared with previously calculated NISS values for the same patients in each data set.

RESULTS

The TISS is more predictive of survival than NISS (Hangzhou: receiver operating characteristic (ROC): NISS = 0.929, TISS = 0.949; p = 0.002; Shenyang: ROC: NISS = 0.924, TISS = 0.942; p = 0.008). Moreover, TISS provides a better fit throughout its entire range of prediction (Hosmer Lemeshow statistic for Hangzhou NISS = 29.71; p < 0.001, TISS = 19.59; p = 0.003; Hosmer Lemeshow statistic for Shenyang NISS = 33.49; p < 0.001, TISS = 21.19; p = 0.002).

CONCLUSIONS

The TISS shows more accurate prediction of prognosis and a linear relation to mortality. The TISS might be a better injury scoring tool with simple computation.

Epidemiology of trauma patients and analysis of 268 mortality cases: trends of a single center in Korea

PURPOSE

There is an increasing incidence of mortality among trauma patients; therefore, it is important to analyze the trauma epidemiology in order to prevent trauma death. The authors reviewed the trauma epidemiology retrospectively at a regional emergency center of Korea and evaluated the main factors that led to trauma-related deaths.

MATERIALS AND METHODS

A total of 17007 trauma patients were registered to the trauma registry of the regional emergency center at Wonju Severance Christian Hospital in Korea from January 2010 to December 2012.

RESULTS

The mean age of patients was 35.2 years old. The most frequent trauma mechanism was blunt injury (90.8%), as well as slip-and-fall down injury, motor vehicle accidents, and others. Aside from 142 early trauma deaths, a total of 4673 patients were admitted for further treatment. The most common major trauma sites of admitted patients were on the extremities (38.4%), followed by craniocerebral, abdominopelvis, and thorax. With deaths of 126 patients during in-hospital treatment, the overall mortality (142 early and 126 late deaths) was 5.6% for admitted patients. Ages ≥55, injury severity score ≥16, major craniocerebral injury, cardiopulmonary resuscitation at arrival, probability of survival <25% calculated from the trauma and injury severity score were independent predictors of trauma mortality in multivariate analysis.

CONCLUSION

The epidemiology of the trauma patients studied was found to be mainly blunt trauma. This finding is similar to previous papers in terms of demographics and mechanism. Trauma patients who have risk factors of mortality require careful management in order to prevent trauma-related deaths.

Risk prediction score for death of traumatised and injured children

BACKGROUND

Injury prediction scores facilitate the development of clinical management protocols to decrease mortality. However, most of the previously developed scores are limited in scope and are non-specific for use in children. We aimed to develop and validate a risk prediction model of death for injured and Traumatised Thai children.

METHODS

Our cross-sectional study included 43,516 injured children from 34 emergency services. A risk prediction model was derived using a logistic regression analysis that included 15 predictors. Model performance was assessed using the concordance statistic (C-statistic) and the observed per expected (O/E) ratio. Internal validation of the model was performed using a 200-repetition bootstrap analysis.

RESULTS

Death occurred in 1.7% of the injured children (95% confidence interval [95% CI]: 1.57-1.82). Ten predictors (i.e., age, airway intervention, physical injury mechanism, three injured body regions, the Glasgow Coma Scale, and three vital signs) were significantly associated with death. The C-statistic and the O/E ratio were 0.938 (95% CI: 0.929-0.947) and 0.86 (95% CI: 0.70-1.02), respectively. The scoring scheme classified three risk stratifications with respective likelihood ratios of 1.26 (95% CI: 1.25-1.27), 2.45 (95% CI: 2.42-2.52), and 4.72 (95% CI: 4.57-4.88) for low, intermediate, and high risks of death. Internal validation showed good model performance (C-statistic = 0.938, 95% CI: 0.926-0.952) and a small calibration bias of 0.002 (95% CI: 0.0005-0.003).

CONCLUSIONS

We developed a simplified Thai pediatric injury death prediction score with satisfactory calibrated and discriminative performance in emergency room settings.

The exponential function transforms the Abbreviated Injury Scale, which both improves accuracy and simplifies scoring

PURPOSE

We present here the exponential function which transforms the Abbreviated Injury Scale (AIS). It is called the Exponential Injury Severity Score (EISS), and significantly outperforms the venerable but dated New Injury Severity Score (NISS) and Injury Severity Score (ISS) as a predictor of mortality.

METHODS

The EISS is defined as a change of AIS values by raising each AIS severity score (1-6) by 3 taking a power of AIS minus 2 and then summing the three most severe injuries (i.e., highest AIS), regardless of body regions. EISS values were calculated for every patient in two large independent data sets: 3,911 and 4,129 patients treated during a 6-year period at the Class A tertiary hospitals in China. The power of the EISS to predict mortality was then compared with previously calculated NISS values for the same patients in each of the two data sets.

RESULTS

We found that the EISS is more predictive of survival [Zhejiang: area under the receiver operating characteristic curve (AUC): NISS = 0.932, EISS = 0.949, P = 0.0115; Liaoning: AUC: NISS = 0.924, EISS = 0.942, P = 0.0139]. Moreover, the EISS provides a better fit throughout its entire range of prediction (Hosmer-Lemeshow statistic for Zhejiang: NISS = 21.86, P = 0.0027, EISS = 13.52, P = 0.0604; Liaoning: NISS = 23.27, P = 0.0015, EISS = 15.55, P = 0.0164).

CONCLUSIONS

The EISS may be used as the standard summary measure of human trauma.

Accidental head trauma during care activities in the first year of life: a neurosurgical comparative study

OBJECTIVES

This study aims to describe clinical-epidemiological data regarding accidental fall injuries occurring during homecare activities among children up to 1 year of age and to compare their outcomes according to the type of trauma.

METHODS

We searched four different hospital databases on head injuries from 1999 to 2009. Patients recorded under the descriptors "accidental fall" and "home-related" in the subtext were selected. Patients were classified into two groups: those who flipped over and fell from a changing table (n = 253) and those who fell from the bed sustaining a direct impact from the floor (n = 483).

RESULTS

There was no difference between both groups with respect to age, gender, and Glasgow Coma Scale score. However, children who suffered injuries after an accidental fall from the changing table were more likely to require surgery (26/483 vs. 57/253, p < 0.0001), had a mean longer length of stay (LOS, 4 vs. 1 day), and a higher incidence of depressed skull fractures (12/483 vs. 24/253, p < 0.0001). Children with a direct impact from the floor after falling off the bed were expected to suffer from simple linear skull fractures, while those who flipped over the changing table were more likely to present facial, soft tissue, or skeletal injuries.

CONCLUSIONS

Children who flipped over a changing table during their homecare activities were more likely to require surgery, showed a higher morbidity, and showed a longer LOS than those who fell down from the bed. These results probably reflect the different impact energy according to each injury mechanism.

Diagnostic accuracy of a single point-of-care prehospital serum lactate for predicting outcomes in pediatric trauma patients

BACKGROUND

Preliminary evidence suggests that a single prehospital lactate level (pLA) improves prediction of morbidity and mortality in adult trauma patients independent of vital signs. However, the value of pLA for pediatric trauma patients is unknown. Our objective was to determine whether pLA is associated with the need for critical care in pediatric trauma patients.

METHODS

We conducted a cohort study of 217 patients transported by helicopter to a level I pediatric trauma center over 24 months. The primary outcome was the need for predefined critical care measures. Covariates included vital signs and Glasgow Coma Scale (GCS) scores documented by prehospital providers.

RESULTS

Forty-one subjects required critical care. Abnormal prehospital vital signs were not associated with need for critical care. Overall, median pLA level for patients who required critical care was 2.1 mmol/L (interquartile range [IQR], 1.6-2.7 mmol/L) versus 1.7 mmol/L (IQR, 1.2-2.2 mmol/L) for those who did not (P = 0.01). In addition, there were 85 subjects who had normal vital signs and a normal GCS during transport. Of these, 11 (13%) required critical care. In the subset of patients with normal prehospital vital signs and GCS, median pLA level for patients who required critical care was 2.6 mmol/L (IQR, 1.8-2.6 mmol/L) versus 1.7 mmol/L (IQR, 1-2.1 mmol/L) for those who did not (P = 0.01).

CONCLUSIONS

Prehospital lactate level was higher in pediatric trauma patients who required critical care, including those who had normal prehospital vital signs and GCS. In this cohort, lactate was an early identifier of children with severe traumatic injuries.

Accidents due to falls from roof slabs

CONTEXT AND OBJECTIVE Falls from the roof slabs of houses are accidents of high potential severity that occur in large Brazilian cities and often affect children and adolescents. The aims of this study were to characterize the factors that predispose towards this type of fall involving children and adolescents, quantify the severity of associated lesions and suggest preventive measures. DESIGN AND SETTING Descriptive observational prospective longitudinal study in two hospitals in the metropolitan region of São Paulo. METHODS Data were collected from 29 cases of falls from roof slabs involving children and adolescents between October 2008 and October 2009. RESULTS Cases involving males were more prevalent, accounting for 84%. The predominant age group was schoolchildren (7 to 12 years old; 44%). Leisure activities were most frequently being practiced on the roof slab at the time of the fall (86%), and flying a kite was the most prevalent game (37.9%). In 72% of the cases, the children were unaccompanied by an adult responsible for them. Severe conditions such as multiple trauma and traumatic brain injuries resulted from 79% of the accidents. CONCLUSION Falls from roof slabs are accidents of high potential severity, and preventive measures aimed towards informing parents and guardians about the dangers and risk factors associated with this type of accident are needed, along with physical protective measures, such as low walls around the slab and gates with locks to restrict free access to these places.

Prevention of child camel jockey injuries: a success story from the United Arab Emirates

OBJECTIVE

To study the effects of a law banning children from taking part in camel racing on child camel jockey injuries in Al-Ain City, United Arab Emirates.

DESIGN

Prospective study.

SETTING

University Teaching Hospital.

PATIENTS

All patients who were admitted to Al-Ain Hospital and were injured while riding camels were prospectively studied between January 1, 2002, and December 31, 2009.

ASSESSMENT OF RISK FACTORS

Two periods, before the law and after its introduction, were compared.

MAIN OUTCOME MEASURES

Pediatric injuries, their anatomical distribution, and severity of injury.

RESULTS

Fifty-four patients were studied, and all were males. There were 13 children and 41 adults. All children were camel jockeys except 1 child who was riding a camel for fun. None of the adult camel riders was a camel jockey. The median (range) age of patients admitted before the law was 12.5 (5-45) years, which was significantly less compared with 27.2 (20-40) years after its introduction (P = 0.001, Mann-Whitney test). All 13 children sustained their injuries before the law was implemented, whereas 12 of 41 adults sustained their injuries before the legislation was in place (P < 0.0001, Fisher exact test). The total length of hospital stay of patients was significantly reduced after the law enforcement (P < 0.01, Mann-Whitney test).

CONCLUSIONS

Our findings emphasize the important role of law enforcement in injury prevention, illustrated by the replacement of children by robot substitutes. This is possibly one of the few examples where child injury has been completely prevented by legislation.

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.

Keeping children safe at home: protocol for three matched case-control studies of modifiable risk factors for falls

BACKGROUND

Childhood falls result in considerable morbidity, mortality and health service use. Despite this, little evidence exists on protective factors or effective falls prevention interventions in young children.

OBJECTIVES

To estimate ORs for three types of medically attended fall injuries in young children in relation to safety equipment, safety behaviours and hazard reduction and explore differential effects by child and family factors and injury severity.

DESIGN

Three multicentre case-control studies in UK hospitals with validation of parental reported exposures using home observations. Cases are aged 0-4 years with a medically attended fall injury occurring at home, matched on age and sex with community controls. Children attending hospital for other types of injury will serve as unmatched hospital controls. Matched analyses will use conditional logistic regression to adjust for potential confounding variables. Unmatched analyses will use unconditional logistic regression, adjusted for age, sex, deprivation and distance from hospital in addition to other confounders. Each study requires 496 cases and 1984 controls to detect an OR of 0.7, with 80% power, 5% significance level, a correlation between cases and controls of 0.1 and a range of exposure prevalences.

MAIN OUTCOME MEASURES

Falls on stairs, on one level and from furniture.

DISCUSSION

As the largest in the field to date, these case control studies will adjust for potential confounders, validate measures of exposure and investigate modifiable risk factors for specific falls injury mechanisms. Findings should enhance the evidence base for falls prevention for young children.

Crossing safety barriers: influence of children's morphological and functional variables

Thirty-three children between 3 and 6 years of age were asked to climb four different types of safety barriers. Morphological and functional variables of the children, which were expected to influence climbing or passing through skills, were collected. The influence of those variables on children's success rate and time to cross was tested. No barrier offered a total restraining efficacy. The horizontal bars barrier was crossed by 97% of the children. In the group of children that succeeded in crossing the four barriers, mean time to cross the most difficult barrier was 15 s. Age was the best predictor for success in crossing most barriers but morphology and strength were important predictors of time to cross. The influence of anthropometric variables in time to cross was dependent upon the characteristics of the barrier. A good design of safety barriers should consider children's age, morphology and strength.

Development and validation of the excess mortality ratio-based Emergency Severity Index

PURPOSE

The purpose of this study is to develop and validate the excess mortality ratio-based Emergency Severity Index (EMR-ESI) that feasibly and objectively assesses the severity of emergency department (ED) patients based on their chief complaints.

METHODS

We used data from the National Emergency Department Information System of Korea from January 2006 to December 2009. We obtained information on mortality and the corresponding chief complaints exhibited by patients presenting to all EDs. The EMR-ESI was computed from the ratio of sex-age standardized hospital mortality for each chief complaint and the sex-age standardized mortality of the entire population of Korea. We tested the discriminatory power of the EMR-ESI on the prediction of hospital outcomes using the area under the receiver operating characteristic curve (AUC) from a multivariate logistic regression model. This model was adjusted for clinical parameters, and the goodness of fit was estimated using the Hosmer-Lemeshow logistic model.

RESULTS

Included in the study were 4 713 462 patients who presented 7557 chief complaint codes from 2006 to 2008. The EMR-ESI had a range of 0 to 6389.45 (mean ± SD, 1.11 ± 4.67; median, 0.70). The adjusted odds ratio of the EMR-ESI (unit, 1.0) for hospital mortality was 1.11 (95% confidence interval, 1.11-1.12). The AUCs for predicting hospital mortality, ED mortality, admission mortality, and admission were 0.95, 0.98, 0.90, and 0.74, respectively. There were 3 422 865 patients from 2009 who were included for external validation, and the AUCs for predicting mortality in the hospital, the ED, the inpatient ward, and for predicting admission were 0.95, 0.99, 0.90, and 0.75, respectively.

CONCLUSION

The EMR-ESI was notably useful in predicting hospital mortality and the admission of emergency patients.

Etiologic factors in falls from height in pediatric cases

OBJECTIVE

In this study, factors causing falls from height and precautions taken for their prevention were investigated.

METHODS

The study was carried out prospectively between June 2009 and June 2010. Patients under 18 years of age presenting at the emergency department of a university hospital, for whom the primary reason for admission was an accidental fall from a height of at least one meter, were included in the study. The demographic characteristics of the patients, the characteristics of the falls, and clinical features were recorded.

RESULTS

Data for 133 patients were evaluated. Among these patients, 72 (54.1%) were male; the median age was 4 (IQR 2-7). The most common fall site was a balcony (38%). Falls frequently happened in the spring and the summer. The mean fall height was 2.9 ± 2.5 m, the median GCS score was 15 (IQR 14-15), and the median PTS was 10 (IQR 9-11). The fall heights was higher in patients who lost consciousness (p < 0.001). Among the 95 patients who were 0-6 years old, it was found that about 55% were unaccompanied by their parents. The most common pathology in the patients was head trauma (63%), while 17.3% had multiple traumas.

CONCLUSION

Since the vast majority of the fall cases were in the pre-school age group, most were due to falls from a balcony, and more than half of the cases were unaccompanied by parents or caregivers, there are two issues that need to be addressed in relation to pediatric falls from height: family education and legal regulations considering child safety in the design of doors, windows, and balconies of buildings.

CT grading scales for splenic injury: why can't we agree?

INTRODUCTION

Computed tomography (CT) has been proven to be able to accurately diagnose splenic injury. Many have published CT splenic injury grading scales to quantify the extent of injury. However, these scales have failed at predicting clinical outcomes and therefore cannot be used to accurately predict the need for intervention. We hypothesised that low interrater reliability is the reason why these scales have failed at predicting clinical outcomes.

METHODS AND MATERIALS

This is a retrospective study of patients who were admitted to the Royal Perth Hospital with blunt splenic injury as coded in the trauma registry. The abdominal CT images of these patients were reviewed by three consultant radiologists and were graded using the six different splenic injury grading scales. We assessed interrater reliability between each of the scales using generalised kappa and proportion of agreement calculations.

RESULTS

The images of 64 patients were reviewed. The interrater reliability yielded a generalised kappa score of 0.32-0.60 and proportion of agreement ranging from 34.4% to 65.5%.

CONCLUSION

The six studied CT splenic injury grading scales did not have a high enough interrater reliability to be adequate for clinical use. The poor interrater reliability is likely to contribute to the failure of the scales at predicting clinical outcomes. Further research to improve the interrater reliability is recommended.

Characteristics of associated craniofacial trauma in patients with head injuries: An experience with 100 cases

BACKGROUND

Facial fractures and concomitant cranial injuries carry the significant potential for mortality and neurological morbidity mainly in young adults.

AIMS AND OBJECTIVES

To analyze the characteristics of head injuries and associated facial injuries, the management options and outcome following cranio-facial trauma.

METHODS

This retrospective review was performed at Justice K. S. Hegde Charitable Hospital, and associated A. B. Shetty Memorial Institute of Dental sciences, Deralakatte, Mangalore. Following Ethical Committee approval, hospital charts and radiographs of 100 consecutive patients of cranio-facial trauma managed at the Department of Oral and Maxillofacial Surgery and Neurosurgery between January 2004 and December 2004 were reviewed.

RESULTS

Majority of the patients were in the 2nd to 4th decade (79%) with a male to female ratio of -8.09:1. Road traffic accidents were the common cause of craniofacial trauma in present study (54%) followed by fall from height (30%). Loss of consciousness was the most common clinical symptom (62%) followed by headache (33%). Zygoma was the most commonly fractured facial bone 48.2% (alone 21.2%, in combination 27.2%). Majority of patients had mild head injury and managed conservatively in present series. Causes of surgical intervention for intracranial lesions were compound depressed fracture, contusion and intracranial hematoma. Operative indications for facial fractures were displaced facial bone fractures. Major causes of mortality were associated systemic injuries.

CONCLUSION

Adult males are the most common victims in craniofacial trauma, and road traffic accidents were responsible for the majority. Most of the patients sustained mild head injuries and were managed conservatively. Open reduction and internal fixation with miniplates was used for displaced facial bone fractures.

Football-related injuries among 6- to 17-year-olds treated in US emergency departments, 1990-2007

Football is one of the most popular youth sports in the United States despite the high rate of injuries. Previously published studies have investigated football-related injuries that occurred in organized play but have excluded those that occurred during unorganized play. Through use of the National Electronic Injury Surveillance System database, cases of football-related injuries were identified for analysis. Sample weights were used to calculate national estimates. An estimated 5 252 721 children and adolescents 6 to 17 years old were treated in US emergency departments for football-related injuries. The annual number of cases increased by 26.5% over the 18-year study period. The 12- to 17-year-old age group accounted for 77.8% of all injuries and had nearly twice the odds of sustaining a concussion. The findings suggest the need for increased prevention efforts to lower the risk of football-related injury in children and adolescents.

[Haemorrhagic shock after severe abdominal trauma in children: knowing when to change from conservative to surgical management]

Abdominal vascular injuries following a serious falling out are quite rare in children. They can lead to haemorrhagic shock whose etiological diagnosis may be difficult in children in case of multiple trauma. The current management of abdominal injuries in the child is usually conservative, surgery being indicated in haemodynamically unstable patients. We report the case of a 7-year-old girl who presented with abdominal trauma with rupture of the hepatic artery and shredding of the splenic vein following a falling out of 10 meters. Aggressive resuscitation associated with early laparotomy for haemostasis, contrary to usual practices advocated in such a context, have helped control the hemorrhagic shock and stabilize the haemodynamic status of the child. The subsequent evolution was favourable, with full recovery. While a conservative attitude usually prevails in the management of traumatic intra abdominal bleeding in children an interventional attitude with emergency surgery must be sometimes considered.

Six years of facial trauma care: an epidemiological analysis of 355 cases

Facial traumas are frequent in emergencies, and they require the diagnosis of fractures and associated lesions.

AIM

To analyze epidemiological data concerning facial trauma care.

MATERIALS AND METHODS

Three hundred and fifty-five charts from patients with facial trauma treated by the Service of Otorhinolaryngology, from January 2002 to December 2008, were revised. The following data was collected: age, gender, etiology, anatomical localization of the fracture, associated injuries, alcohol consumption, treatment, and hospitalization.

STUDY DESIGN

A retrospective historical longitudinal study.

RESULTS

Most of the patients are young adult men (p<0.05) with a male:female ratio of 4:1(p<0.05). Interpersonal violence is the most prevalent cause of facial trauma (27.9%), followed by motor vehicle accidents (16.6%) (p<0.05). The mandible is the most prevalent facial bone fractured (44.2%), followed by nasal fracture (18.9%) (p<0.05). 41.1% of the patients consumed alcohol with a male:female ratio of 11.2:1 (p<0.05). Seventy-seven percent of the patients required surgical intervention (p<0.05) and 84.5% were hospitalized (p<0.05).

CONCLUSION

Young male adults are the most prevalent victims of facial trauma, and interpersonal violence is responsible for the majority of the facial injuries. Most of the cases of facial trauma are associated with the consumption of alcohol. Further studies will be necessary to provide a clear understanding of the trends in the etiology of facial trauma.

An update on the epidemiology of pediatric fractures

Despite public health measures to prevent childhood injuries, the incidence of pediatric fractures is increasing. This fracture incidence is dependent on many demographic factors, the various contributors to bone health, and an individual's risk-taking behavior. Although traditional play activities continue to be the prevalent causes for fractures, there is an evolving array of new sport and recreation activities that carry significant fracture risk. The following review article outlines the developing epidemiology of pediatric fractures by analyzing some of the individual risk factors that influence fracture incidence as well as the variety of activities that are associated with these fractures.

Epidemiology of balcony fall-related injuries, United States, 1990-2006

BACKGROUND

Falls from heights are common in urban areas in the United States. This study describes the epidemiology of balcony fall-related injuries requiring emergency department (ED) treatment among children and adults in the United States from 1990 through 2006.

METHODS

In 2009, a retrospective analysis of data from the National Electronic Injury Surveillance System of the US Consumer Product Safety Commission was conducted to describe the epidemiology of balcony fall-related injuries.

RESULTS

An estimated 86,500 (95% confidence interval [CI], 68,400-104,600) balcony fall-related injuries were treated in US hospital EDs from 1990 through 2006; 70% of cases were male; 63% were adults (≥18 years old); 94% of injury events occurred at home; 24% of patients were hospitalized; and 8 patients died. The rate of balcony fall-related injuries among children decreased significantly during 1990 to 2006 and was similar to that of adults by the end of the study period. Fall heights ranged from 5 to 87.5 ft. Structural failure of the balcony was involved in an estimated 5600 cases. Patients younger than 18 years were more likely to sustain a concussion/closed head injury (relative risk, 2.42; 95% CI, 1.84-3.18) or skull fracture (relative risk, 5.86; 95% CI, 2.58-13.30) than adults.

CONCLUSIONS

This is the first study of balcony fall-related injuries requiring emergency treatment using a nationally representative sample. Balcony falls are an important cause of injury in the United States. Age, male sex, and warm months of the year were associated with balcony fall-related injuries in our study population.

Fatal accidental fall from height in infants and children: a study from South Delhi

One hundred and seventy-four deaths of infants and children due to accidental fall from height received from South Delhi for autopsy were studied during the 10-year period from January 1998 to December 2007 at the All India Institute of Medical Sciences, New Delhi. Data were analysed with regard to age, sex, location of fall, height of fall, pattern of injury, cause of death and seasonal variation. These cases represented approximately 22.56% of all deaths due to a fall from height and 1.31% of all medicolegal autopsies conducted during the period. There were 106 male (60.9%) and 68 female (39.1%) victims. Age-specific rate of fall showed that the highest rate was in toddlers (39.65%), followed by 26.43% each in preschool children and school-going children and the least in infants (7.47%). The head and face was the most frequently injured body region (93.67%) and the skull was the commonest bone fractured (59.19%). The most common cause of death was head injury (84.48%). Major fall sites in decreasing order of frequency were rooftop (38.50%), balcony (24.13%), household furniture (21.26%), staircase (6.89%), window (4.59%), wall (1.72%), rickshaw/bicycle (1.15%) and tree (0.57%). Most fatalities due to a fall from height were reported in the rainy season.

Ten years of new injury severity score (NISS): is it a possible change?

The article is a bibliographic review which intends to present the actual range of researches comparing the Injury Severity Score (ISS) and the New Injury Severity Score (NISS). Databases were searched using the keyword NISS, with 42 articles, 23 of which didn't compare the two indexes. Most part of the 19 selected articles showed that NISS has been more accurate in predicting the outcomes (dependent variables) than ISS, moreover in severe and specific trauma. Studies with populations between 1,000 and 10,000 resulted in NISS-favorable results, whereas studies with populations larger than 10,000 or smaller than 1,000 showed either NISS-favorable results or no difference between the two groups. However, there were no studies showing ISS-favorable results. These results and the easier calculation of NISS lead to a future replacement of ISS by NISS.

Bunk bed-related injuries among children and adolescents treated in emergency departments in the United States, 1990-2005

OBJECTIVE

Our goal was to comprehensively examine bunk bed-related injuries in the United States by using a nationally representative sample.

METHODS

Using the National Electronic Injury Surveillance System database, cases of nonfatal bunk bed-related injuries treated in US emergency departments from 1990 through 2005 were selected by using the National Electronic Injury Surveillance System bunk bed product code (0661). Cases concerning individuals </=21 years old were included.

RESULTS

An estimated 572 580 children and adolescents aged </=21 years were treated in US emergency departments for bunk bed-related injuries during the 16-year study period, yielding an average of 35 790 cases annually. An average of 42 per 100 000 population were treated annually. Bunk bed-related injuries occurred more frequently among males (60.6%). Lacerations were the most common type of injury (29.7%), followed by contusions and abrasions (24.0%) and fractures (19.9%). The body parts most frequently injured were the head and neck (27.3%) in all age groups. Falls were the most common mechanism of injury (72.5%). Of the cases for which locale of injury was recorded, 93.5% occurred at home. Approximately half of the bunk bed-related injuries that occurred at schools involved individuals aged 18 to 21 years (50.9%). An estimated 2.9% of injuries resulted in hospitalization or transfer to another hospital or required additional observation. The number of bunk bed-related injuries showed no significant trend from 1990 to 2005.

CONCLUSIONS

Bunk beds are a common source of injury among children and adolescents, and these injuries mostly involve the head and face. Given the continuing large numbers of bunk bed-related injuries at homes and in schools, increased efforts are needed to prevent bunk bed-related injuries among children and adolescents.

Falls among children in the developing world: a gap in child health burden estimations?

AIM

To estimate the incidence and mortality rates for unintentional fall injuries in children under 5 years of age in three developing regions of the world.

METHODS

This is a systematic review of literature on unintentional childhood fall injuries. A computerized PUBMED search of literature published between 1980 and 2006 was conducted and a manual search of journals was also completed.

RESULTS

Over 140,000 injuries to children under 19 years were reported in 56 studies (21 from Asia, 20 from Africa and 15 from South America); on an average 36% of injuries (52 575) were due to falls. The median incidence is estimated at 137.5 fall injuries per 100,000 children. The incidence of falls specific to the under-5 age group was reported in 16 studies with a median incidence of 40.6 falls per 100,000. The overall average incidence rate for childhood falls is highest in South America at 1315 followed by Asia at 1036 and Africa at 786 per 100,000, respectively. Average mortality rates were highest for Asia at 27 followed by Africa at 13.2 per 100,000, respectively.

CONCLUSION

This review demonstrates that the burden of falls on children has not been well documented, and is most likely under-reported. With the large and growing population of children in developing countries, the public health implications of the observed results are tremendous. Appropriate prevention relies on accurate statistics.

Major trauma and the injury severity score--where should we set the bar?

Major trauma is commonly defined using an Injury Severity Score (ISS) threshold of 15. Since this threshold was formulated, there have been significant developments in both the Abbreviated Injury Scale underlying the ISS, and trauma management techniques, both in the preventive and acute-care phases of trauma management. This study assesses whether this ISS threshold is appropriate when evaluating both mortality, and hospital-based indicators of morbidity, in a paediatric population using a large hospital trauma registry. Other registries and datasets using ISS >15 as an inclusion criterion may exclude a substantial body of data relating to significantly morbid trauma patients.