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Prehospital interventions in severely injured pediatric patients: Rethinking the ABCs
Kyle K Sokol1, George E Black, Kenneth S Azarow
1From the Department of Surgery (K.K.S., G.E.B., M.J.M., M.J.E.), Madigan Army Medical Center, Tacoma, Washington; and Department of Surgery (K.S.A.), Oregon Health Sciences University; and Trauma and Acute Care Surgery Service (W.L., M.J.M.), Legacy Emanuel Hospital, Portland, Oregon.
Insights
Prehospital interventions (PHIs) for pediatric war casualties in Afghanistan show circulation interventions effectively control hemorrhage. Airway interventions, however, were linked to increased mortality in severe traumatic brain injury cases.
Area of Science:
- Pediatric Trauma Care
- Military Medicine
- Emergency Medical Services
Background:
- Wartime conflicts generate a high volume of severely injured pediatric patients.
- Austere environments necessitate effective prehospital interventions (PHIs) for casualty survival during transport.
Purpose of the Study:
- To analyze the utilization and outcomes of prehospital interventions in pediatric casualties during the Afghanistan conflict.
- To identify the most effective PHIs for severe wartime injuries in children.
Main Methods:
- Retrospective review of the Department of Defense Trauma Registry for pediatric patients (≤18 years) treated at Camp Bastion (2004-2012).
- PHIs categorized by Advanced Trauma Life Support (ATLS) as Airway (A), Breathing (B), and Circulation (C).
- Outcomes assessed via injury severity, hemodynamics, blood product/fluid administration, and mortality rates.
Main Results:
- 20% of 766 pediatric patients received PHIs, predominantly Circulation (C, 51%), followed by Airway (A, 40%).
- Circulation interventions (tourniquets, hemostatic dressings) were associated with reduced need for blood products and fluids.
- Airway interventions, primarily for severe traumatic brain injury (TBI), correlated with significantly higher mortality (OR 5.9).
Conclusions:
- Circulation PHIs are crucial for hemorrhage control in pediatric wartime injuries and should be prioritized in training and equipment.
- Airway interventions in pediatric TBI patients are associated with adverse outcomes and warrant cautious application.
- Breathing interventions were infrequently used but appeared safe and potentially underutilized.
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.
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