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Characterization of organ dysfunction and mortality in pediatric patients with trauma with acute traumatic
Alison Nair1, Heidi Flori2, Mitchell Jay Cohen3
1Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.
Insights
Pediatric acute traumatic coagulopathy (ATC) is linked to organ dysfunction and mortality. Early identification of ATC in children is crucial for improving outcomes after severe injury.
Area of Science:
- Pediatric Traumatology
- Hemostasis and Coagulation
- Critical Care Medicine
Background:
- Traumatic injuries significantly impact pediatric mortality and morbidity.
- Abnormalities in hemostasis, including acute traumatic coagulopathy (ATC), are critical factors in poor outcomes.
- Pediatric ATC, an early response to injury, is increasingly recognized.
Purpose of the Study:
- To evaluate the epidemiology of pediatric acute traumatic coagulopathy (ATC).
- To determine the association between pediatric ATC and organ dysfunction.
- To identify predictors of mortality and morbidity in pediatric trauma patients.
Main Methods:
- Retrospective analysis of pediatric trauma patients (2006-2015) with coagulation testing at presentation.
- Exclusion criteria included age >18, non-mechanical injury, anticoagulation use, and delayed testing (>4 hours).
- ATC defined as International Normalized Ratio (INR) ≥1.3; primary outcome was multiple organ dysfunction syndrome (MODS).
Main Results:
- Of 7382 patients, 545 met criteria; 16% (88 patients) had ATC.
- Patients with ATC had significantly higher rates of MODS (68.4% vs 7.7%) and in-hospital mortality (26.1% vs 0.4%).
- ATC, arterial hypotension, and Injury Severity Score ≥30 were independent predictors of MODS and mortality.
Conclusions:
- Pediatric ATC is associated with increased organ dysfunction, mortality, and morbidities.
- ATC, hypotension, and high injury severity independently predict poor outcomes in pediatric trauma.
- Pediatric ATC may differ biologically from adult ATC, warranting further investigation.
Background:
Traumatic injuries are a leading cause of mortality and morbidity in pediatric patients and abnormalities in hemostasis play an important role in these poor outcomes. One such abnormality, acute traumatic coagulopathy (ATC), is a near immediate endogenous response to injury and has recently been described in the pediatric population. This study aims to evaluate the epidemiology of pediatric ATC, specifically its association with organ dysfunction.
Methods:
All patients with trauma presenting to the University of California, Benioff Children's Hospital Oakland between 2006 and 2015 with coagulation testing drawn at presentation were included. Patients were excluded if they (1) were >18 years of age, (2) were admitted with a non-mechanical mechanism of injury, (3) were on anticoagulation medications, or (4) had coagulation testing >4 hours after injury. ATC was defined as an international normalized ratio (INR) ≥1.3. The primary outcome was new or progressive multiple organ dysfunction syndrome (MODS) and secondary outcomes included in-hospital mortality and other morbidities.
Results:
Of the 7382 patients that presented in the 10-year study period, 545 patients met criteria for analysis and 88 patients (16%) presented with ATC. Patients with ATC were more likely to develop MODS than those without ATC (68.4% vs 7.7%, p<0.001) and had higher in-hospital mortality (26.1% vs 0.4%, p<0.001) than those without ATC. Along with arterial hypotension and an Injury Severity Score ≥30, ATC was independent predictor of MODS and in-hospital mortality. An isolated elevated INR was associated with MODS and in-hospital mortality while an isolated elevated partial thromboplastin time was not.
Conclusions:
Pediatric ATC was associated with organ dysfunction, mortality, and other morbidities. ATC along with arterial hypotension and high injury severity were independent predictors of organ dysfunction and mortality. Pediatric ATC may be biologically distinct from adult ATC and further studies are needed.
Level Of Evidence:
IV, epidemiologic.
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