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

      Highlights

      • 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.

      Abstract

      Introduction

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

      Methods

      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.

      Results

      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.

      Discussion

      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.

      Keywords

      Abbreviations:

      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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      References

        • Pearson E.G.
        • Fitzgerald C.A.
        • Santore M.T.
        Pediatric thoracic trauma: current trends.
        Semin Pediatr Surg. 2017; 26 (FebEpub 2017 Jan 11. PMID: 28302283): 36-42https://doi.org/10.1053/j.sempedsurg.2017.01.007
        • Bliss D.
        • Silen M.
        Pediatric thoracic trauma.
        Crit Care Med. 2002; 30 (NovSupplPMID: 12528782): S409-S415https://doi.org/10.1097/00003246-200211001-00005
        • Peclet M.H.
        • Newman K.D.
        • Eichelberger M.R.
        • Gotschall C.S.
        • Garcia V.F.
        • Bowman L.M.
        Thoracic trauma in children: an indicator of increased mortality.
        J Pediatr Surg. 1990; 25 (Sepdiscussion 965-6PMID: 2213448): 961-965https://doi.org/10.1016/0022-3468(90)90238-5
        • Reynolds S.L.
        Pediatric thoracic trauma: recognition and management.
        Emerg Med Clin N Am. 2018; 36 (MayEpub 2018 Feb 10. PMID: 29622335): 473-483https://doi.org/10.1016/j.emc.2017.12.013
        • Tovar J.A.
        • Vazquez J.J.
        Management of chest trauma in children.
        Paediatr Respir Rev. 2013; 14 (JunEpub 2013 Apr 15. PMID: 23598068): 86-91https://doi.org/10.1016/j.prrv.2013.02.011
        • Balci A.E.
        • Kazez A.
        • Eren S.
        • Ayan E.
        • Ozalp K.
        • Eren M.N.
        Blunt thoracic trauma in children: review of 137 cases.
        Eur J Cardiothorac Surg. 2004; 26 (AugPMID: 15296902): 387-392https://doi.org/10.1016/j.ejcts.2004.04.024
        • Mollberg N.M.
        • Tabachnick D.
        • Lin F.J.
        • Merlotti G.J.
        • Varghese T.K.
        • Arensman R.M.
        • Massad M.G.
        Age-associated impact on presentation and outcome for penetrating thoracic trauma in the adult and pediatric patient populations.
        J Trauma Acute Care Surg. 2014; 76 (Febdiscussion 277-8PMID: 24458033): 273-277https://doi.org/10.1097/TA.0000000000000090
        • Barry W.E.
        • Barin E.
        • McLaughlin C.M.
        • Strumwasser A.
        • Shekherdimian S.
        • Arbogast H.
        • Upperman J.S.
        • Jensen A.R.
        Pediatric firearm injuries in Los Angeles County: younger children are more likely to be the victims of unintentional firearm injury.
        J Pediatr Surg. 2019; 54 (FebEpub 2018 Oct 22. PMID: 30414690): 350-353https://doi.org/10.1016/j.jpedsurg.2018.10.050
        • Demetriades D.
        • Martin M.
        • Salim A.
        • Rhee P.
        • Brown C.
        • Chan L.
        The effect of trauma center designation and trauma volume on outcome in specific severe injuries.
        Ann Surg. 2005; 242 (Octdiscussion 517-9PMID: 16192811; PMCID: PMC1402347): 512-517https://doi.org/10.1097/01.sla.0000184169.73614.09
        • Demetriades D.
        • Martin M.
        • Salim A.
        • Rhee P.
        • Brown C.
        • Doucet J.
        • Chan L.
        Relationship between American college of surgeons trauma center designation and mortality in patients with severe trauma (injury severity score >15).
        J Am Coll Surg. 2006; 202 (Febquiz A45Epub 2005 Dec 19. PMID: 16427544): 212-215https://doi.org/10.1016/j.jamcollsurg.2005.09.027
        • Osler T.M.
        • Vane D.W.
        • Tepas J.J.
        • Rogers F.B.
        • Shackford S.R.
        • Badger G.J.
        Do pediatric trauma centers have better survival rates than adult trauma centers? An examination of the National Pediatric Trauma Registry.
        J Trauma. 2001; 50 (JanPMID: 11231677): 96-101https://doi.org/10.1097/00005373-200101000-00017
        • Densmore J.C.
        • Lim H.J.
        • Oldham K.T.
        • Guice K.S.
        Outcomes and delivery of care in pediatric injury.
        J Pediatr Surg. 2006; 41 (Jandiscussion 92-8PMID: 16410115): 92-98https://doi.org/10.1016/j.jpedsurg.2005.10.013
        • Notrica D.M.
        • Weiss J.
        • Garcia-Filion P.
        • Kuroiwa E.
        • Clarke D.
        • Harte M.
        • Hill J.
        • Moffat S.
        Pediatric trauma centers: correlation of ACS-verified trauma centers with CDC statewide pediatric mortality rates.
        J Trauma Acute Care Surg. 2012; 73 (Sepdiscussion 570-2PMID: 22929485): 566-570https://doi.org/10.1097/TA.0b013e318265ca6f
        • Walther A.E.
        • Falcone R.A.
        • Pritts T.A.
        • Hanseman D.J.
        • Robinson B.R.
        Pediatric and adult trauma centers differ in evaluation, treatment, and outcomes for severely injured adolescents.
        J Pediatr Surg. 2016; 51 (AugEpub 2016 Apr 12. PMID: 27132539; PMCID: PMC5558261): 1346-1350https://doi.org/10.1016/j.jpedsurg.2016.03.016
        • Checchi K.D.
        • Calvo R.Y.
        • Badiee J.
        • Rooney A.S.
        • Sise C.B.
        • Sise M.J.
        • Bansal V.
        • Martin M.J.
        Association of trauma center level and patient volume with outcomes for penetrating thoracic trauma.
        J Surg Res. 2020; 255 (NovEpub 2020 Jun 30. PMID: 32619859): 442-448https://doi.org/10.1016/j.jss.2020.05.089
        • Sewalt C.A.
        • Wiegers E.J.A.
        • Venema E.
        • Lecky F.E.
        • Schuit S.C.E.
        • Den Hartog D.
        • Lingsma H.F.
        The volume-outcome relationship in severely injured patients: a systematic review and meta-analysis.
        J Trauma Acute Care Surg. 2018; 85 (OctPMID: 30086069): 810-819https://doi.org/10.1097/TA.0000000000002043
        • Cooper A.
        • Hannan E.L.
        • Bessey P.Q.
        • Farrell L.S.
        • Cayten C.G.
        • Mottley L.
        An examination of the volume-mortality relationship for New York State trauma centers.
        J Trauma. 2000; 48 (Jandiscussion 23-4PMID: 10647560): 16-23https://doi.org/10.1097/00005373-200001000-00004
        • Tepas JJ 3rd
        • Patel J.C.
        • DiScala C.
        • Wears R.L.
        • Veldenz H.C.
        Relationship of trauma patient volume to outcome experience: can a relationship be defined?.
        J Trauma. 1998; 44 (Maydiscussion 830-1PMID: 9603084): 827-830https://doi.org/10.1097/00005373-199805000-00014
        • Osler T.
        • Glance L.
        • Buzas J.S.
        • Mukamel D.
        • Wagner J.
        • Dick A.
        A trauma mortality prediction model based on the anatomic injury scale.
        Ann Surg. 2008; 247 (JunPMID: 18520233): 1041-1048https://doi.org/10.1097/SLA.0b013e31816ffb3f
        • Walther A.E.
        • Pritts T.A.
        • Falcone R.A.
        • Hanseman D.J.
        • Robinson B.R.
        Teen trauma without the drama: outcomes of adolescents treated at Ohio adult versus pediatric trauma centers.
        J Trauma Acute Care Surg. 2014; 77 (Juldiscussion 116PMID: 24977764): 109-116https://doi.org/10.1097/TA.0000000000000277
        • Wang N.E.
        • Saynina O.
        • Vogel L.D.
        • Newgard C.D.
        • Bhattacharya J.
        • Phibbs C.S.
        The effect of trauma center care on pediatric injury mortality in California, 1999 to 2011.
        J Trauma Acute Care Surg. 2013; 75 (OctPMID: 24064887; PMCID: PMC4306425): 704-716https://doi.org/10.1097/TA.0b013e31829a0a65
        • Sathya C.
        • Alali A.S.
        • Wales P.W.
        • Scales D.C.
        • Karanicolas P.J.
        • Burd R.S.
        • Nance M.L.
        • Xiong W.
        • Nathens A.B.
        Mortality among injured children treated at different trauma center types.
        JAMA Surg. 2015; 150 (SepPMID: 26106848): 874-881https://doi.org/10.1001/jamasurg.2015.1121