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Pediatric trauma surgery in Iraq and Afghanistan: Mortality, indicators, and most common operating room interventions
Andrew S Oh1, Steven G Schauer, Kathleen Adelgais
1From the Section of Pediatric Emergency Medicine, Department of Pediatrics (A.S.O., K.A.), University of Colorado School of Medicine, Aurora, Colorado; US Army Institute of Surgical Research (S.G.S.), Brooke Army Medical Center, San Antonio, Texas; Department of Surgery, Oregon Health Sciences University (J.L.F.), Portland, Oregon; and Division of Pediatric Surgery, Department of Pediatrics (F.K.), University of Colorado School of Medicine, Aurora, Colorado.
Insights
Most pediatric casualties in Iraq and Afghanistan required surgery, with older age, specific injury types, and massive transfusions predicting operative intervention. Surgical management significantly improved survival rates for these young patients.
Area of Science:
- Military Medicine
- Pediatric Surgery
- Trauma Surgery
Background:
- Wars in Afghanistan and Iraq resulted in numerous pediatric casualties.
- Significant military medical resources were allocated to treating these young patients.
- Understanding the characteristics of surgically treated pediatric casualties is crucial.
Purpose of the Study:
- To describe the characteristics of pediatric casualties who underwent operative intervention in Iraq and Afghanistan.
- To identify factors associated with requiring operative intervention.
- To assess the impact of operative intervention on survival.
Main Methods:
- Retrospective analysis of pediatric casualties in the Department of Defense Trauma Registry.
- Inclusion criteria: US military treatment, at least one operative intervention, survival to emergency department.
- Descriptive statistics, inferential statistics, and multivariable modeling were used.
Main Results:
- 75% of 3,388 eligible pediatric casualties required operative intervention (median 4 procedures).
- Operative casualties were older, male, with higher rates of explosive/firearm injuries and greater injury severity.
- Operative intervention was associated with improved survival (95% vs. 82%) and reduced mortality (OR 7.43).
Conclusions:
- The majority of pediatric casualties in military treatment facilities underwent operative intervention.
- Older age, massive transfusion, explosive, and firearm injuries were associated with increased likelihood of surgery.
- Operative management demonstrated a significant association with improved survival outcomes.
Background:
The wars in Afghanistan and Iraq produced thousands of pediatric casualties, using substantial military medical resources. We sought to describe characteristics of pediatric casualties who underwent operative intervention in Iraq and Afghanistan.
Methods:
This is a retrospective analysis of pediatric casualties treated by US Forces in the Department of Defense Trauma Registry with at least one operative intervention during their course. We report descriptive, inferential statistics, and multivariable modeling to assess associations for receiving an operative intervention and survival. We excluded casualties who died on arrival to the emergency department.
Results:
During the study period, there were a total of 3,439 children in the Department of Defense Trauma Registry, of which 3,388 met inclusion criteria. Of those, 2,538 (75%) required at least 1 operative intervention totaling 13,824 (median, 4; interquartile range, 2-7; range, 1-57). Compared with nonoperative casualties, operative casualties were older and male and had a higher proportion of explosive and firearm injuries, higher median composite injury severity scores, higher overall blood product administration, and longer intensive care hospitalizations. The most common operative procedures were related to abdominal, musculoskeletal, and neurosurgical trauma; burn management; and head and neck. When adjusting for confounders, older age (unit odds ratio, 1.04; 1.02-1.06), receiving a massive transfusion during their initial 24 hours (6.86, 4.43-10.62), explosive injuries (1.43, 1.17-1.81), firearm injuries (1.94, 1.47-2.55), and age-adjusted tachycardia (1.45, 1.20-1.75) were all associated with going to the operating room. Survival to discharge on initial hospitalization was higher in the operative cohort (95% vs. 82%, p < 0.001). When adjusting for confounders, operative intervention was associated with improved mortality (odds ratio, 7.43; 5.15-10.72).
Conclusion:
Most children treated in US military/coalition treatment facilities required at least one operative intervention. Several preoperative descriptors were associated with casualties' likelihood of operative interventions. Operative management was associated with improved mortality.
Level Of Evidence:
Prognostic and Epidemiological; Level III.
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