Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs.

Abstract

BACKGROUND:

The current conflict in Afghanistan has resulted in a high volume of significantly injured pediatric patients. The austere environment has demanded emphasis on prehospital interventions (PHIs) to sustain casualties during transport.

METHODS:

The Department of Defense Trauma Registry was queried for all pediatric patients (≤18 years) treated at Camp Bastion from 2004 to 2012. PHIs were grouped by Advanced Trauma Life Support categories into (1) airway (A)--intubation or surgical airway; 2) breathing (B)--chest tube or needle thoracostomy; and 3) circulation (C)--tourniquet or hemostatic dressing. Outcomes were assessed based on injury severity, hemodynamics, blood products and fluids, as well as mortality rates.

RESULTS:

There were 766 injured children identified with 20% requiring one or more PHIs, most commonly circulation (C, 51%) followed by airway (A, 40%) and breathing (B, 8.7%). The majority of C interventions were tourniquets (85%) and hemostatic dressings (15%). Only 38% of patients with extremity vascular injury or amputation received a C intervention, with a significant reduction in blood products and intravenous fluids associated with receiving a C PHI (both p < 0.05). A interventions consisted of endotracheal intubation for depressed mental status (Glasgow Coma Scale [GCS] score < 8). Among patients with traumatic brain injury, A interventions were associated with higher unadjusted mortality (56% vs. 20%, p < 0.01) and remained independently associated with increased mortality after multivariate adjustment (odds ratio, 5.9; p = 0.001). B interventions were uncommon and performed in only 2% of patients with no recorded adverse outcomes.

CONCLUSION:

There is a high incidence of PHIs among pediatric patients with severe wartime injuries. The most common and effective were C PHI for hemorrhage control, which should remain a primary focus of equipment and training. A interventions were most commonly performed in the setting of severe traumatic brain injury but were associated with worse outcomes. B interventions seem safe and effective and may be underused.

LEVEL OF EVIDENCE:

Care management/therapeutic study, level IV.

• Authors: Kyle K Sokol, George E Black, Kenneth S Azarow, William Long, Matthew J Martin, Matthew J Eckert
• Journal: The journal of trauma and acute care surgery (J Trauma Acute Care Surg) Vol. 79 Issue 6 Pg. 983-9; discussion 989-90 (Dec 2015) ISSN: 2163-0763 [Electronic] United States
• PMID: 26680137 (Publication Type: Journal Article)

Topics

• Adolescent
• Afghan Campaign 2001-
• Afghanistan (epidemiology)
• Child
• Child, Preschool
• Emergency Medical Services
• Emergency Treatment (methods)
• Female
• Humans
• Infant
• Infant, Newborn
• Male
• Registries
• Wounds and Injuries (epidemiology, therapy)