Validation of Rules to Predict Emergent Surgical Intervention in Pediatric Trauma Patients

Abstract

Background Trauma centers use guidelines to determine when a trauma surgeon is needed in the emergency department (ED) on patient arrival. A decision rule from Loma Linda University identified patients with penetrating injury and tachycardia as requiring emergent surgical intervention. Our goal was to validate this rule and to compare it to the American College of Surgeons’ Major Resuscitation Criteria (MRC). Study Design We used data from 1993 through 2010 from two Level 1 trauma centers in Denver, Colorado. Patient demographics, injury severity, times of ED arrival and surgical intervention, and all variables of the Loma Linda Rule and the MRC were obtained. The outcome, emergent intervention (defined as requiring operative intervention by a trauma surgeon within one hour of arrival to the ED or performance of cricothyroidotomy or thoracotomy in the ED) was confirmed using standardized abstraction. Sensitivities, specificities, and 95% confidence intervals (CIs) were calculated. Results 8,078 patients were included and 47 (0.6%) required emergent intervention. Of the 47 patients, the median age was 11 years (IQR: 7–14), 70% were male, 30% had penetrating mechanisms, and the median ISS was 25 (IQR: 9–41). At the two institutions, the Loma Linda Rule had a sensitivity and specificity of 69% (95% CI: 45%–94%) and 76% (95% CI: 69%–83%), respectively, and the MRC had a sensitivity and specificity of 80% (95% CI: 70%–92%) and 81% (95% CI: 77%–85%), respectively. Conclusions Emergent surgical intervention is rare in the pediatric trauma population. Although precision of predictive accuracies of the Loma Linda Rule and MRC were limited by small numbers of outcomes, neither set of criteria appears to be sufficiently accurate to recommend their routine use.

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

“…We performed a secondary analysis of an established data set developed to evaluate trauma triage, containing prospectively collected EMS and trauma registry data and retrospectively collected patient outcomes data 26 . This study was approved by the institutional review board and is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology Statement and a complete checklist has been uploaded as Supplemental Digital Content (SDC), http://links.lww.com/TA/C566.…”

Nationwide use of REBOA in adolescent trauma patients: An analysis of the AAST AORTA registry

“…Pediatric patients sustain mostly blunt trauma, most commonly falls and motor vehicle collisions, and are for the most part not severely injured, with around 60% of reported injury severity scores less than 8 [14]. Additionally, pediatric trauma patients are known to undergo invasive procedures rarely, with the most notable example being resuscitative thoracotomy with rates as low as 0.17% of pediatric patients at two level 1 trauma centers in Denver, Colorado undergoing resuscitative thoracotomy over a 17-year period [15]. The overall rate of emergency procedural or operative intervention was only 0.6% (47 patients of 8,078) over the same period and was most commonly laparotomy [15].…”

“…Additionally, pediatric trauma patients are known to undergo invasive procedures rarely, with the most notable example being resuscitative thoracotomy with rates as low as 0.17% of pediatric patients at two level 1 trauma centers in Denver, Colorado undergoing resuscitative thoracotomy over a 17-year period [15]. The overall rate of emergency procedural or operative intervention was only 0.6% (47 patients of 8,078) over the same period and was most commonly laparotomy [15]. However, there exists a subgroup of pediatric trauma patients who succumb to their injuries, and most do so within the first 24 hours [1].…”

Pediatric emergency department thoracotomy: A 40-year review

“…Survival has repeatedly been demonstrated to be poor in this age group. There are several studies that report 0% survival[8, 12]. These small case series only include 17 and 9 patients respectively.…”

“…Case series reporting pediatric EDT survival rates range from 0 to 26% [5-12]. A recent meta analysis has compiled these studies and reported a significant survival advantage in patients who sustain penetrating versus blunt injury [6].…”