Impact of Trauma Center Type on Outcomes in Pediatric Population Following Severe Isolated Blunt Traumatic Brain Injuries: A National Analysis

INTRODUCTION

This study aims to evaluate the association between trauma center type, verification level, and clinical outcomes in pediatric trauma patients with moderate and severe isolated blunt traumatic brain injury (TBI).

METHODS

This is a retrospective cohort study utilizing the American College of Surgeons (ACS) Trauma Quality Program (TQP) Participant Use File (PUF) database from 2017 to 2021. Severely injured pediatric (<18 years) trauma patients with isolated moderate and severe TBI (AIS head >2, all other body regions <3) were included. Outcomes included in-hospital mortality, discharge disposition, intensive care unit length-of-stay (ICU-LOS), and ventilator-free days (VFDs).

RESULTS

Patients treated at a level-I combined adult and pediatric trauma centers (CTCs) had significantly lower odds of in-hospital mortality than those treated at adult trauma centers (ATCs) (OR .495, 95% CI 0.291-.841, P = .009). Patients treated at level-I pediatric trauma centers (PTCs) (OR 2.726, 95% CI 2.059-3.609, P < .001) and level-II PTCs (OR 6.18, 95% CI 3.402-11.239, P < .001) were significantly more likely to be discharged home than equivalent-level ATCs.

CONCLUSION

Pediatric patients with isolated blunt moderate and severe TBI treated at level-I PTCs and CTCs had reduced odds of in-hospital mortality compared to level-I ATCs. Patients at level I and II PTCs had significantly higher odds of discharge home than those at equivalent-level CTCs and ATCs.

No Difference in Mortality and Outcomes After Addition of a Nearby Pediatric Trauma Center

OBJECTIVES

Previous studies demonstrate that higher volume pediatric trauma centers (PTCs) offer improved outcomes. This study evaluated pediatric trauma volume and outcomes at an existing level I (L-I) adult and level II (L-II) PTC after the addition of a new children's hospital L-II PTC within a 2-mile radius, hypothesizing no difference in mortality and complications.

METHODS

A retrospective review of patients aged 14 years or younger presenting to a single adult L-I and L-II PTC was performed. Patients from 2015-2016 (PRE) were compared with patients from 2018-2019 (POST) for mortality and complications using bivariate analyses.

RESULTS

Compared with the PRE cohort, there were less patients in the POST cohort (277 vs 373). Patients in the POST cohort had higher rates of insurance coverage (91.3% vs 78.8%, P < 0.001), self-transportation (7.2% vs 2.7%, P < 0.01), and hospital admission (72.6% and 46.1%, P < 0.001). There was no difference in all complications and mortality (all P > 0.05) between the 2 cohorts.

CONCLUSIONS

After opening a second L-II PTC within a 2-mile radius, there was an increase in the rate of admissions and self-transportation to the preexisting L-II PTC. Despite a nearly 26% decrease in pediatric trauma volume, there was no difference in length of stay, hospital complications, or mortality.

Pediatric Traumatic Brain Injury in a Geographically Dispersed Population: A Relationship Between Distance to Definitive Neurosurgical Treatment and Outcome

BACKGROUND

There are limited data on the association between transport distance and outcomes in pediatric patients with severe traumatic brain injuries (sTBIs), despite children having to travel further to pediatric trauma centers (PTCs).

OBJECTIVE

To assess whether distance from a PTC is associated with outcomes in children who undergo cranial surgery after sTBI.

METHODS

Children with sTBI who underwent craniectomy/craniotomy at our PTC between 2010 and 2019 were identified retrospectively. Of these 92 patients, 83 sustained blunt injury and underwent surgery within 24 hours. The distance from injury location to PTC was based on injury zip code and calculated as Euclidean distance. Variables associated with transport, including distance, time, and rural-urban disparity, were analyzed for correlation with poor outcome.

RESULTS

Of the 83 patients identified, 81 had injury location information. Forty patients were injured within 30 miles and 41 were injured ≥30 miles from the PTC. Injury severity and pediatric trauma scores were not significantly different between groups. Sixty-eight children (82%) had a satisfactory outcome and 10 children (12%) died. There was a nonsignificant association between distance traveled and poor outcome, even when the cohort was stratified into those with subdural hematomas and those with nonabusive injuries.

CONCLUSIONS

Regardless of the distance from the PTC at which their injury occurred, most children in this cohort made a moderate to good recovery. Children injured at greater distances from the PTC did not have worse outcomes; however, studies with larger cohorts are needed to more definitively assess prehospital pediatric transport systems in this population.

Does the mechanism matter? Comparing thrombelastography between blunt and penetrating pediatric trauma patients

BACKGROUND/PURPOSE

The utility of thrombelastography (TEG) in pediatric trauma remains unknown, and differences in coagulopathy between blunt and penetrating mechanisms are not established. We aimed to compare TEG patterns in pediatric trauma patients with blunt solid organ injuries (BSOI) and penetrating injuries to determine the role of mechanism in coagulopathy.

METHODS

Highest-level pediatric trauma activations with BSOI or penetrating injuries and admission TEG at two pediatric trauma centers were included. TEG abnormalities were defined by each institution's normative values and compared separately by injury mechanism and evidence of shock (elevated SIPA) using Kruskal-Wallis or Fisher's exact tests.

RESULTS

Of 118 patients included, 64 had BSOI and 54 had penetrating injuries. There were no significant differences in TEG abnormalities between the BSOI and penetrating injury groups. Patients with shock were more likely to have decreased alpha-angles (30.9% vs. 8.0%, p = 0.01) and decreased maximum amplitude (MA) (44.1% vs. 8.0%, p < 0.001) compared to those without shock, regardless of mechanism of injury.

CONCLUSIONS

TEG abnormalities were not significantly different between the BSOI and penetrating groups, but there were significant differences in alpha-angle and MA in those with shock, independent of mechanism. Hemodynamic status, rather than mechanism of injury, may be more predictive of coagulopathy in pediatric trauma patients.

LEVEL OF EVIDENCE/STUDY TYPE

Level III, retrospective.

Laparoscopy in the Evaluation of Blunt Abdominal Injury in Level-I and II Pediatric Trauma Centers

Introduction

An American College of Surgeons (ACS) Level-I (L-I) pediatric trauma center demonstrated successful laparoscopy without conversion to laparotomy in ∼65% of trauma cases. Prior reports have demonstrated differences in outcomes based on ACS level of trauma center. We sought to compare laparoscopy use for blunt abdominal trauma at L-I compared to Level-II (L-II) centers.

Methods

The Pediatric Trauma Quality Improvement Program was queried (2014-2016) for patients ≤16 years old who underwent any abdominal surgery. Bivariate analyses comparing patients undergoing abdominal surgery at ACS L-I and L-II centers were performed.

Results

970 patients underwent abdominal surgery with 14% using laparoscopy. Level-I centers had an increased rate of laparoscopy (15.6% vs 9.7%, P = .019 ); however they had a lower mean Injury Severity Score (16.2 vs 18.5, P = .002) compared to L-II centers. Level-I and L-II centers had similar length of stay ventilator days, and SSIs (all P > .05).

Conclusion

While use of laparoscopy for pediatric trauma remains low, there was increased use at L-I compared to L-II centers with no difference in LOS or SSIs. Future studies are needed to elucidate which pediatric trauma patients benefit from laparoscopic surgery.

Comparison of Computed Tomography Use and Mortality in Severe Pediatric Blunt Trauma at Pediatric Level I Trauma Centers Versus Adult Level 1 and 2 or Pediatric Level 2 Trauma Centers

INTRODUCTION

Computed tomography (CT) is the criterion standard for identifying blunt trauma injuries in pediatric patients, but there are long-term risks of CT exposure. In pediatric blunt trauma, multiple studies have shown that increased CT usage does not necessarily equate to improvements in mortality. The aim of this study was to compare CT usage between level 1 pediatric trauma centers versus level 2 pediatric centers and adult level 1 and 2 centers.

METHODS

We performed a retrospective, multicenter analysis of National Trauma Data Bank patient records from the single admission year of 2015. Eligible subjects were defined as younger than 18 years with abdominal or thoracic blunt trauma, had an Injury Severity Scale score of greater than 15, and were treated at a level 1 or 2 trauma center. Data were then compared between children treated at level 1 pediatric trauma centers (PTC group) versus level 2 PTCs or adult level 1/2 trauma centers (ATC group). The primary outcomes measured were rates of head, thoracic, abdominal CT, and mortality. Data from ATC and PTC groups were propensity matched for age, sex, race, and Glasgow Coma Scale.

RESULTS

There were 6242 patients after exclusion criteria. Because of differences in patient demographics, we propensity matched 2 groups of 1395 patients. Of these patients, 39.6% of PTC patients received abdominal CT versus 45.5% of ATC patients (P = 0.0017). Similarly, 21.9% of PTC patients received thoracic CT versus 34.7% of ATC patients (P < 0.0001). There was no difference in head CT usage between PTC and ATC groups (P = 1.0000). There was no significant difference in mortality between patients treated in the PTC versus ATC groups (P = 0.1198).

CONCLUSIONS

Among children with severe blunt trauma, patients treated at level 1 PTCs were less likely to receive thoracic and abdominal CTs than those treated at level 2 pediatric or adult trauma level 1/2 centers, with no significant differences in mortality. These findings support the use of selective imaging in severe blunt pediatric trauma.