Pediatric penetrating thoracic trauma: Examining the impact of trauma center designation and penetrating trauma volume on outcomes


      • Previous literature shows superior outcomes for traumatically injured patients treated at Level I trauma centers. We sought to determine if this applies to pediatric patients with penetrating thoracic injuries.
      • Retrospective review (2013–2016) demonstrated outcomes improved when patients were treated at adult Level I centers and with increased annual case volume.
      • Firearms were responsible for the majority of penetrating injuries in these pediatric patients and accounted for the highest injury burden and majority of deaths.



      We analyzed the impact of treating center designation and case volume of penetrating trauma on outcomes after pediatric penetrating thoracic injuries (PTI).


      PTI patients <18 years were identified from the National Trauma Data Bank (2013–2016). Centers were categorized by type (Pediatric or Adult) and designation status (Level I, Level II, and other). Performance was calculated as the difference between observed and expected mortality and standardized using the total penetrating trauma volume per center. Expected mortality was calculated using the Trauma Mortality Prediction Model. Pearson correlation and linear mixed-effects models evaluated the association between variables and performance.


      We identified 4,134 PTI patients treated at 596 trauma centers: 879 (21%) at Adult Level I, 608 (15%) at Adult Level II, 531 (13%) at Pediatric Level I, 320 (8%) at Pediatric Level II, and 1,796 (43%) at other centers. Primary injury mechanisms were firearm-related (58%) and cut/piercing (42%). Overall mortality was 16% and median predicted mortality was 3.6% (IQR: 1.5% - 11.2%). Among patients with thoracic firearm-related injuries, centers with lower penetrating case volume and total trauma care demonstrated significantly worse outcomes. Multivariable analysis revealed Adult Level I centers had superior outcomes compared with all other non-Level I centers. There was no difference in mortality between Pediatric and Adult Level I centers.


      Adult Level I trauma center designation and annual case volume of penetrating thoracic trauma are associated with improved mortality after pediatric firearm-related thoracic injuries. Further study is needed to identify factors in higher volume centers that improve outcomes.

      Level of evidence

      Level III.



      ACS (American college of surgeons), AIS (abbreviated injury scale), ICU (intensive care unit), ISS (injury severity score), NTDB (national trauma data bank), PTI (penetrating thoracic injury), TMPM (trauma mortality prediction model)
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