You might not have spotted that the Trauma Audit and Research Network (TARN)1 published an updated report on paediatric trauma last week. You can find the full document here 2.This document is important because it provides us with an overview of the sort of paediatric trauma patients we are seeing across England and Wales, what sort of injuries they have and what happens to them. The last iteration of the report provided much of the data used by both Ross and me in preparing talks on paediatric trauma for conferences3,4 (my talk from #smaccMINI in Dublin should be out soon and I’ll add the link here when it is).
The latest version covers data collected between January 2013 and December 2014 and contains data about 5402 children (under 16 years of age).
What does the report tell us about paediatric injuries?
There are 1511 children scoring an Injury Severity Score of >15: that means these children either have injuries to multiple body areas or severe injuries to one or more areas (you can find out about the Injury Severity Score here5 along with an ISS calculator). It is this cohort of patients that TARN is particularly interested in and about whom the report is written.
Attendances are more likely in the summer months (April to October) with presentations at weekends and in the evenings. The data shows that still around 1 in 4 severely injured children presents by a transport modality other than ambulance or helicopter: this is important because the inherently portable nature of children means that parents often perceive that it is quicker to put the child in the family car and drive them to the nearest Emergency Department. They might be right, but this also means that trauma triage bypass systems are not activated as they would be by ambulance services, and so seriously injured children are not always taken directly to paediatric major trauma centres. This means that all ED clinicians should be prepared to look after seriously injured children, at least in the initial assessment and resuscitation phase, even if your department is not a major trauma centre or does not routinely see children at all. In fact, <50% present first to a department classified as a paediatric major trauma centre.
Who are the patients and how are they injured?
Around 1/5 of the patients in the dataset were under the age of 12 months. This is both interesting and concerning as non-mobile children should struggle to achieve the momentum required to sustain severe trauma (unless they are involved in road traffic collisions). The report tells us that almost 10% of all of the patients with ISS>15 were injured non-accidentally (under 2 years) and is a stark reminder of how important it is to keep this in mind.
Road traffic collisions were the most common mechanism of injury (41.6%) and in 50% of cases the child was a pedestrian. Falls <2m were the next most common mechanism (20.2%). Penetrating trauma is rare, accounting for 0.8% overall.
The median age of the patients in the report was 6 years, 6 months and there were more than twice as many male as female patients (68.6% vs 31.4%).
The data tells us that 119 of the 1511 severely injured children died as a result of their injuries – 8.6% overall. The highest number of deaths occurred as a result of severe traumatic brain injury but the highest proportion was seen in groups exposed to asphyxia or drowning. Both drowning and asphyxia are relatively rare but frequently fatal, with mortality rates of 77.4% for asphyxia and 45.5% for drowning.
Drowning is particularly important as it might require different treatment from other trauma presentations. Unfortunately it is rather more common in Australia and as such the Royal Children’s Hospital in Melbourne6 has some succinct guidelines which are well worth a read.
What does this mean for us in the Emergency Department (and Prehospital)?
We all need to be prepared to assess and resuscitate children with major trauma, no matter where we work. It is helpful to be familiar with guidance such as the Royal College of Radiologists Guidelines for Imaging in Paediatric Trauma7,8 and also to note that in 90% of severe trauma presenting to a children’s MTC there was an ED consultant on hand to provide care. This means that these consultants are also available for advice – and in my experience they don’t say no to seeing patients if you are concerned about them.
38% of children had definitive airway management (endotracheal intubation, cricothyroidotomy or tracheostomy) with just under a quarter of those performed pre-hospital and just over half in the Emergency Department. The median time to securing the airway was 1.2 hours. If you don’t work in a paediatric major trauma centre it is worth considering how this would happen in your department – are you comfortable dealing with the paediatric airway? Would you be waiting for someone else to attend the department – and how long would this take? Of course this has to be considered on a case-by-case basis but it is always worth thinking about what you would do in that hair-raising situation. Tim Horeczko’s paediatric airway tips from smaccMINI should be out soon too!
There are also some implications here for public health messages around the transport of children (with regard to the benefits of prehospital trauma triage) and a reminder to all of us to consider non-accidental injury in all of the patients we see but particularly those severely injured under the age of two years.
Above all there is reason to be positive – despite serious injuries, death from paediatric trauma is relatively rare and with thought, training and teamwork we can hope to see this proportion fall even further.
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