An Analysis of Outcomes and Interventions for Female Pediatric Casualties in Iraq and Afghanistan.

BACKGROUND: Traumatic injuries were the most common reason for admission of pediatric patients to military hospitals during the recent wars in Iraq and Afghanistan. We compare survival and interventions between female and male pediatric casualties. MATERIALS AND METHODS: This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry. We requested pediatric encounters from January 2007 to January 2016 within Iraq and Afghanistan. We separated casualties by sex to compare injury and mortality patterns. RESULTS: Our initial dataset included 3439 pediatric encounters-784 (22.8%) females and 2655 (77.2%) males. Females were less likely to sustain injuries by explosive (38.0% versus 44.5%) but more likely to sustain injuries via alternative mechanisms of injury (28.9% versus 21.5%). Both sexes had similar ISS (females median 10 [5-17], males 10 [4-17]). Fewer females underwent tourniquet application (4.2% versus 7.2%; all findings were significant). In unadjusted and adjusted regression analyses, females under age 8 had lower odds of survival to hospital discharge (OR 0.67, 95% CI 0.51-0.89) compared to males. CONCLUSIONS: Among pediatric patients treated by U.S. medical personnel in Iraq and Afghanistan, females had a lower survival to hospital discharge despite similar severity of injury. Further studies are necessary to elucidate causes for this finding.

An analysis of the pediatric casualties undergoing massive transfusion in Iraq and Afghanistan.

BACKGROUND: Existing data on pediatric massive transfusion as part of trauma resuscitation is limited. We report the characteristics of pediatric casualties associated with undergoing massive transfusion at US military treatment facilities during combat operations in Iraq and Afghanistan. METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. We stratified subjects by Centers for Disease Control age groupings: <1, 1-4, 5-9, 10-14, and 15-17 years. We defined a massive transfusion as 40 mL/kg of total blood products or more. RESULTS: From January 2007 through January 2016 there were 3439 pediatric casualties within the registry, of which 543 (15.7%) met criteria for receiving a massive transfusion. The median age of children undergoing massive transfusion was 9 years (IQR 5-12), male (73.4%), injured in Afghanistan (69.9%) and injured by explosives (60.4%). Compared to other pediatric casualties, subjects undergoing massive transfusion had higher composite injury severity scores (median 17 versus 9), higher incidence of tachycardia (86.8% versus 70.9%), increased incidence of hypotension (31.2% versus 7.5%), and decreased survival to hospital discharge (82.6% versus 91.6%). Specific to body regions, casualties undergoing massive transfusion more frequently had serious injuries to the head/neck (30.0% versus 22.8%), the thorax (22.8% versus 9.9%), abdomen (26.8% versus 6.9%), the extremities (42.1% versus 14.6%), while less frequently had serious injuries to the skin (5.3% versus 8.4%). All findings were significant. CONCLUSIONS: Further research is needed to better translate the lessons learned from pediatric trauma care in the combat setting into the civilian setting in developed countries. LEVEL OF EVIDENCE: 3.

Pediatric Trauma Patient Intensive Care Resource Utilization in U.S. Military Operations in Iraq and Afghanistan.

Children represent a unique patient population treated by military personnel during wartime, as seen in the recent conflicts in Iraq and Afghanistan. We sought to describe ICU resource utilization by U.S. military personnel treating pediatric trauma patients in Iraq and Afghanistan. DESIGN: This is a retrospective review of prospectively collected data within Department of Defense Trauma Registry. SETTING: We studied pediatric casualties treated in U.S. and coalition military hospitals in Iraq and Afghanistan between January 2007 and January 2016. PATIENTS: We queried the Department of Defense Trauma Registry for patients less than 18 years with one documented day within an ICU. INTERVENTIONS: We used descriptive statistics to analyze injuries patterns and interventions. We defined prolonged length of stay as ICU stay four days or greater. Regression methodology was utilized to identify factors associated with prolonged length of stay. MEASUREMENTS AND MAIN RESULTS: There were 1955 (56.8%) pediatric patients that met our inclusion criteria. The most common mechanism of injury was explosive (45.2%) followed by gunshot wounds (20.8%). The median composite ISS was 14. The median length of stay was 3 days with 90.2% surviving to hospital discharge. Mechanical ventilation was the most frequent intervention (67.6%) followed by arterial access (21.8%). Prolonged length of stay was associated with all serious injuries, ventilator management, blood product administration, wound dressing, bronchoscopy, imaging, and central venous access. CONCLUSIONS: Pediatric casualties accounted for nearly one in 10 admissions with the majority requiring intensive care. The most commonly performed interventions were mechanical ventilation, vascular access, and imaging, each of which requires a specialized skill set to provide optimal patient management. All serious injuries by body region except facial were associated with a prolonged length of ICU stay, as well as blood product administration, ventilator management, intracranial pressure monitoring, wound care, bronchoscopy, imaging, and central venous access. The epidemiology of this unique population may be useful in planning future pre-deployment training and resource management in ICUs in deployed environments.