Pediatric trauma surgery in Iraq and Afghanistan: Mortality, indicators, and most common operating room interventions from 2007 to 2016.

BACKGROUND: The wars in Afghanistan and Iraq produced thousands of pediatric casualties, using substantial military medical resources. We sought to describe characteristics of pediatric casualties who underwent operative intervention in Iraq and Afghanistan. METHODS: This is a retrospective analysis of pediatric casualties treated by US Forces in the Department of Defense Trauma Registry with at least one operative intervention during their course. We report descriptive, inferential statistics, and multivariable modeling to assess associations for receiving an operative intervention and survival. We excluded casualties who died on arrival to the emergency department. RESULTS: During the study period, there were a total of 3,439 children in the Department of Defense Trauma Registry, of which 3,388 met inclusion criteria. Of those, 2,538 (75%) required at least 1 operative intervention totaling 13,824 (median, 4; interquartile range, 2-7; range, 1-57). Compared with nonoperative casualties, operative casualties were older and male and had a higher proportion of explosive and firearm injuries, higher median composite injury severity scores, higher overall blood product administration, and longer intensive care hospitalizations. The most common operative procedures were related to abdominal, musculoskeletal, and neurosurgical trauma; burn management; and head and neck. When adjusting for confounders, older age (unit odds ratio, 1.04; 1.02-1.06), receiving a massive transfusion during their initial 24 hours (6.86, 4.43-10.62), explosive injuries (1.43, 1.17-1.81), firearm injuries (1.94, 1.47-2.55), and age-adjusted tachycardia (1.45, 1.20-1.75) were all associated with going to the operating room. Survival to discharge on initial hospitalization was higher in the operative cohort (95% vs. 82%, p < 0.001). When adjusting for confounders, operative intervention was associated with improved mortality (odds ratio, 7.43; 5.15-10.72). CONCLUSION: Most children treated in US military/coalition treatment facilities required at least one operative intervention. Several preoperative descriptors were associated with casualties' likelihood of operative interventions. Operative management was associated with improved mortality. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

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

BACKGROUND: The American College of Surgeons (ACS) requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation. Our goal was to evaluate the effect of adding age-adjusted shock index (SI) to the ACS-6 for the prediction of severe injury among pediatric trauma patients with the hypothesis that SI would significantly improve sensitivity with an acceptable decrease in specificity. METHODS: We performed a secondary analysis of prospectively collected EMS and trauma registry data from two urban pediatric trauma centers. Age-adjusted SI thresholds were calculated as heart rate divided by systolic blood pressure using 2020 Pediatric Advanced Life Support SI vital sign ranges and previously published Shock Index, Pediatric Adjusted (SIPA) thresholds. The primary outcome was a composite of emergency operative (within 1 hour of arrival) or emergency procedural intervention (EOPI) or Injury Severity Score (ISS) greater than 15. Sensitivities, specificities, and 95% CIs were calculated for the ACS-6 alone and in combination with age-adjusted SI. RESULTS: There were 8,078 patients included; 20% had an elevated age-adjusted SI and 17% met at least one ACS minimum criterion; 1% underwent EOPI; and 17% had ISS >15. Sensitivity and specificity of the ACS-6 for EOPI or ISS > 5 were 45% (95% confidence interval [CI], 41-50%) and 89% (95% CI, 81-96%). Inclusion of Pediatric Advanced Life Support-SI and SIPA resulted in sensitivities of 51% (95% CI, 47-56%) and 69% (95% CI, 65-72%), and specificities of 80% (95% CI, 71-89%) and 60% (95% CI, 53-68%), respectively. Similar trends were seen for each secondary outcome. CONCLUSION: In this cohort of pediatric trauma registry patients, the addition of SIPA to the ACS-6 for trauma team activation resulted in significantly increased sensitivity for EOPI or ISS greater than 15 but poor specificity. Future investigation should explore using age-adjusted shock index in a two-tiered trauma activation system, or in combination with novel triage criteria, in a population-based cohort. LEVEL OF EVIDENCE: Diagnostic Tests or Criteria; Level II.

Confidential Screening for Sex Trafficking Among Minors in a Pediatric Emergency Department.

OBJECTIVES: Child sex trafficking is a global health problem, with a prevalence of 4% to 11% among high-risk adolescents. The objective of this study was to confidentially administer a validated screening tool in a pediatric emergency department by using an electronic tablet to identify minors at risk for sex trafficking. Our hypothesis was that this modality of administration would adequately identify high-risk patients. METHODS: English- and Spanish-speaking patients from the ages of 12 to 17 years presenting to a large urban pediatric emergency department with high-risk chief complaints were enrolled in a prospective cohort over 13 months. Subjects completed a previously validated 6-item screening tool on an electronic tablet. The screening tool's sensitivity, specificity, and positive and negative predictive values were calculated. Multivariable logistic regression was performed to identify additional risk factors. RESULTS: A total of 212 subjects were enrolled (72.6% female; median age: 15 years; interquartile range 13-16), of which 26 patients were subjected to child sex trafficking (prevalence: 12.3%). The sensitivity and specificity of the electronic screening tool were 84.6% (95% confidence interval [CI] 70.8%-98.5%) and 53.2% (95% CI 46.1%-60.4%), respectively. The positive predictive value and negative predictive value were 20.2% (95% CI 12.7%-27.7%) and 96.1% (95% CI 92.4%-99.9%), respectively. A previous suicide attempt and history of child abuse increased the odds of trafficking independent of those who screened positive but did not improve sensitivity of the tool. CONCLUSIONS: A confidentially administered, previously validated, electronic screening tool was used to accurately identify sex trafficking among minors, suggesting that this modality of screening may be useful in busy clinical environments.

Sensitivity of plain pelvis radiography in children with blunt torso trauma.

STUDY OBJECTIVE: Plain anteroposterior pelvic radiographs are commonly used to screen children for pelvic fractures or dislocations after blunt torso trauma. The test sensitivity and utility, however, are unclear. We assessed the sensitivity of anteroposterior pelvic radiographs for identifying children with pelvic fractures or dislocations after blunt torso trauma. We hypothesized that anteroposterior pelvic radiographs fail to identify all children with pelvic fractures or dislocations, including patients undergoing operative intervention and those with hypotension. METHODS: We conducted a prospective multicenter observational study of children (<18 years) with blunt torso trauma in the Pediatric Emergency Care Applied Research Network. We compared plain anteroposterior pelvic radiographs to the final diagnosis of pelvic fractures or dislocations as documented by the orthopedic faculty physician before emergency department (ED)/hospital discharge. We described the data with descriptive statistics, including 95% confidence intervals (CIs). RESULTS: Of 12,044 patients enrolled in the parent study, 451 (3.7%; 95% CI 3.4% to 4.1%) had pelvic fractures or dislocations. Of these patients, 65 (14%; 95% CI 11% to 18%) underwent operative intervention and 21 (4.7%; 95% CI 2.9% to 7.0%) had age-adjusted hypotension on initial presentation. In the ED, 382 of the 451 patients underwent plain anteroposterior pelvic radiographs, with a sensitivity of 297 of 382 (78%; 95% CI 73% to 82%) for patients with pelvic fractures or dislocations, 55 of 60 (92%; 95% CI 82% to 97%) for patients undergoing operative intervention, and 14 of 17 (82%; 95% CI 57% to 96%) for patients with hypotension. CONCLUSION: Plain anteroposterior pelvic radiographs have a limited sensitivity for identifying children with pelvic fractures or dislocations after blunt trauma, including patients undergoing operative intervention and those with hypotension.

Cervical spine computed tomography utilization in pediatric trauma patients.

BACKGROUND: Guidelines for evaluating the cervical spine in pediatric trauma patients recommend cervical spine CT (CSCT) when plain radiographs suggest an injury. Our objective was to compare usage of CSCT between a pediatric trauma center (PTC) and referral general emergency departments (GEDs). METHODS: Patient data from a pediatric trauma registry from 2002 to 2011 were analyzed. Rates of CSI and CSCT of patients presenting to the PTC and GED were compared. Factors associated with use of CSCT were assessed using multivariate logistic regression. RESULTS: 5148 patients were evaluated, 2142 (41.6%) at the PTC and 3006 (58.4%) at the GED. Groups were similar with regard to age, gender, GCS, and triage category. GED patients had a higher median ISS (14 vs. 9, p<0.05) and more frequent ICU admissions (44.3% vs. 26.1% p<0.05). CSI rate was 2.1% (107/5148) and remained stable. CSCT use increased from 3.5% to 16.1% over time at the PTC (mean 9.6% 95% CI=8.3, 10.9) and increased from 6.8% to 42.0% (mean 26.9%, CI=25.4, 28.4) at the GED. Initial care at a GED remained strongly associated with CSCT. CONCLUSIONS: Despite a stable rate of CSI, rate of CSCT increased significantly over time, especially among patients initially evaluated at a GED.

Use of helical computed tomography for imaging the pediatric cervical spine.

OBJECTIVE: To determine the differences in resource utilization and radiation exposure between conventional radiography (ConvRad) and helical computed tomography (HCT) when used to survey the pediatric cervical spine (CSp). METHODS: Patients aged 0-14 years who required CSp radiographic evaluation in addition to cranial CT were prospectively enrolled and assigned to undergo either HCT or ConvRad with adjunctive linear tomography. Outcomes of medication usage, emergency department (ED) length of stay (LOS), cervical spine radiation exposure, and imaging resource use (relative value unit [RVU]) were compared between the two groups. Data were analyzed by regression analysis with adjustment for confounders. RESULTS: Of 136 patients, 64 and 72 patients were assigned to the ConvRad group and HCT group, respectively. At the discretion of the trauma team, 34% of the patients enrolled crossed between the two study arms. Odds ratio (OR), based on original assignment, was 0.8 (95% CI = 0.4 to 1.8) for difference in medication usage between the two groups. Mean LOSs were 259 minutes (95% CI = 124 to 394) and 183 (95% CI = 166 to 200) minutes for HCT and ConvRad, respectively. CSp imaging RVUs were 5.5 (95% CI = 5.1 to 5.8) for HCT and 4.0 (95% CI = 3.3 to 4.6) for ConvRad. Mean CSp radiation doses were 389 mRem (95% CI = 346 to 432) for HCT and 294 mRem (95% CI = 245 to 343) for ConvRad. Adjustment for confounders did not change the direction of the results. CONCLUSIONS: As a modality to screen the pediatric CSp for blunt-force trauma, HCT results in increased radiation exposure and radiology resource use without a reduction in sedation usage or time in the ED.