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Article 1
Direct to operating room trauma resuscitation decreases mortality among severely injured children. Wieck MM, Cunningham AJ, Behrens B, Ohm ET, Maxwell BG, Hamilton NA, Adams MC, Cole FJ Jr, Jafri MA. J Trauma Acute Care Surg. 2018 Oct;85(4):659-664.
Some adult trauma centers have successfully implemented direct to operating room (DOR) resuscitation. This involves bypassing the trauma bay and taking the patient directly to the OR for evaluation and any necessary interventions. This process has been shown to decrease time to operative intervention and improve survival in adult patients but has not been studied in pediatric patients. Wieck et al. aimed to evaluate their urban ACS Level 1 Pediatric Trauma Center experience with DOR resuscitation. This was a retrospective review of their prospectively-maintained database over eight years (2009-2016). 82 patients were included in the analysis. 76% were admitted from the field with 24% transferring from a referring hospital. The following criteria were used for DOR admission (with proportion of study patients with each criteria): chest injury (32%); rigid, distended abdomen (1%); evisceration of abdominal contents (4%); penetrating injury, including impaled object, in neck, chest, abdomen, or pelvis (62%); traumatic amputations (6%); age-specific hypotension (11%); significant blood loss on scene or in route (7%); cardiopulmonary arrest due to trauma (11%); physician discretion (15%).
82% of DOR patients required emergent procedural intervention. Though the most commonly performed procedure was wound exploration or repair, 54% required major procedures (laparotomy, thoracotomy, craniotomy, neck exploration or vascular repair). Overall survival of these patients was 84%. None of the above criteria was an individually significant predictor of the need for emergent intervention. Observed mortality was compared to expected mortality using TRISS (Trauma Injury Severity Score) methodology. Overall, DOR patients had a trend toward lower mortality (16% observed vs 21% predicted) but this was only significant in penetrating trauma (16% observed vs 26% predicted). Overall hospital costs for DOR patients compared to non-DOR patients were similar.
A protocol for DOR resuscitation of severely injured pediatric patients shows a trend to reduction in overall mortality in the appropriate patients. This mortality benefit is statistically significant in penetrating trauma. Trauma centers that have the available resources and structural footprint to do so, should consider DOR resuscitation for select pediatric patients.
Article 2
Individual and neighborhood characteristics of children seeking emergency department care for firearm injuries within the PECARN network. Carter PM, Cook LJ, Macy ML, Zonfrillo MR, Stanley RM, Chamberlain JM, Fein JA, Alpern ER, Cunningham RM. Acad Emerg Med. 2017 Jul;24(7):803-813.
Firearm violence was the second leading cause of death among United States children in 2013. A prominent focus in the literature has been on fatal firearm injuries in children, whereas there is a deficit of information regarding children sustaining nonfatal firearm injuries. This paper by Carter et al. aimed to evaluate the characteristics of children with nonfatal firearm injuries as well as describe the individual and neighborhood risk factors for these injuries. The study was a secondary analysis of data from the PECARN (Pediatric Emergency Care Applied Research Network) core data project. The study evaluated data from 16 hospitals over five years (2004-2008). There was a total of 1,758 ED visits included in the study. The prevalence of firearm injuries overall increased with increasing age. Additionally, the proportion of assault injury (compared to self-inflicted and unintentional injuries) increased with increasing age; however, it must be noted that unintentional firearm injury is a significant problem in the younger age groups (<10 years old). A multivariate analysis compared firearm-related injury visits to non-firearm-related visits to the ED and this demonstrated the following risk factors among children for nonfatal firearm injuries: male sex, minority race/ethnicity, older aged youth and higher neighborhood socioeconomic disadvantage.
Male sex, minority status, adolescence and socioeconomic disadvantage are independent risk factors among children for nonfatal firearm injury. These risk factors can help guide further efforts in prevention of firearm injuries whether they be accidental or assault. An interesting side note seen in the study described that almost 20% of children suffering a firearm injury had been seen in the same ED within the prior 12 months, potentially allowing an opportunity for preventative counseling.
Article 3
Twenty years of pediatric gunshot wounds in our community: Have we made a difference? Bayouth L, Lukens-Bull K, Gurien L, Tepas III JJ, Crandall M. J Pediatr Surg. 2019 Jan;54(1):160-164.
Over the last two decades firearm violence is responsible for the death of more than 35,000 children. As aforementioned firearm injury has become the second leading cause of pediatric death. Bayouth et al. aimed to evaluate the pediatric firearm injuries seen over the last 20 years (1996-2016) at their Level 1 Trauma Center in Jacksonville, FL (located in the most violent urban county of the state). This was a retrospective review of the center’s trauma registry that included all patients age 0-18 years who suffered a gunshot wound (GSW). 898 patients were identified. 81.5% of GSWs were assaultive. There was an overall mortality rate of 10%. There was a significant variation in annual incidence of GSWs but no overall longitudinal trend during the study period. Geographic information system (GIS) mapping demonstrated significant geographic clustering of GSWs with one particular zip code having the highest overall and annual incidence of GSWs. The highest rates of GSWs occurred in zip codes that were the most socioeconomically and resource impoverished with no change over time despite multiple efforts including increased police presence, violence intervention programs and aggressive seizure of illegal firearms.
Pediatric firearm violence is most prevalent in socioeconomically deprived areas in this urban center. Though this may or may not be reliably generalized to other urban areas, an assumption could be made that this is common based on other previous studies including that by Carter et al. above. Most importantly, the addition of violence intervention programs and increased policing have not been able to combat the socioeconomic factors that appear to be driving the prevalent firearm violence in the high-hazard areas of the city, suggesting that other, potentially higher-level, interventions are needed to counteract the socioeconomic forces driving violence in these areas.
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