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Does pediatric trauma center designation matter for children in shock from gunshot wounds? A Trauma Quality
Micaela K Gomez1, Elizabeth C Wood, Maximilian Peter Forssten
1From the Department of Vascular Surgery (M.K.G.), Wake Forest University, Winston-Salem, North Carolina; Department of General Surgery (M.K.G.), University of Arizona, Tucson, Arizona; Department of Surgery (E.C.W.), Wake Forest School of Medicine, Winston Salem, North Carolina; Department of Orthopedic Surgery (M.P.F.), Orebro University Hospital, Sweden, School of Medical Sciences, Orebro University, Sweden; Department of Vascular and Endovascular Surgery (T.K.W.), Wake Forest School of Medicine, Winston Salem, North Carolina; Department of Orthopedic Surgery (S.P.F.), Orebro University Hospital, Orebro, Sweden; Center of Trauma and Critical Care (B.S.), George Washington University, Washington, DC; Department of Surgery, School of Medical Sciences (S.M.), Orebro University, Sweden; and Department of Pediatric Surgery (L.P.N.), Wake Forest School of Medicine, Winston-Salem, North Carolina.
Insights
Pediatric gunshot wound patients did not show improved outcomes at pediatric trauma centers compared to adult trauma centers. Adult trauma centers are crucial for managing these complex pediatric firearm injuries effectively.
Area of Science:
- Trauma Surgery
- Pediatric Critical Care
- Public Health
Background:
- Pediatric trauma centers (PTCs) generally improve outcomes for severely injured children.
- However, immediate life-saving interventions for specific injuries may negate PTC benefits over adult trauma centers (ATCs).
- Pediatric gunshot wounds (GSWs) present unique challenges requiring immediate intervention.
Purpose of the Study:
- To compare clinical outcomes of hypotensive pediatric trauma patients with GSWs treated at PTCs versus ATCs.
- To determine if PTC verification status impacts outcomes for pediatric GSW patients.
Main Methods:
- Utilized the 2013-2021 Trauma Quality Improvement Program data.
- Identified hypotensive pediatric patients (≤15 years) with GSWs, excluding those with severe regional injury (AIS=6) or transfer status.
- Employed Poisson regression models to analyze the association between trauma center type and patient outcomes.
Main Results:
- Analyzed 687 pediatric GSW patients; 34% treated at PTCs.
- PTC patients were slightly younger (median 10 vs. 12 years).
- No significant differences observed in Injury Severity Score, crude mortality rates, in-hospital mortality, complications, failure to rescue, ICU admission, or mechanical ventilation between PTCs and ATCs after adjustment.
Conclusions:
- Pediatric GSWs are a significant clinical challenge, predominantly managed at ATCs.
- Current data do not support a survival or outcome benefit for treating pediatric GSW patients at PTCs.
- ATCs play a vital role in managing pediatric firearm injuries, aligning with readiness requirements for ACS-verified centers.
Background:
Recent studies have demonstrated improved outcomes for severely injured pediatric trauma patients treated at pediatric trauma centers (PTCs). Nonetheless, specific injury patterns requiring immediate lifesaving intervention may offset the recognized benefits of PTC over adult trauma centers (ATCs). This study aims to compare the clinical outcomes of hypotensive pediatric trauma patients with gunshot wounds (GSWs), based on trauma center type. We hypothesize that outcomes are equivalent for this clinical scenario.
Methods:
The 2013-2021 Trauma Quality Improvement Program data set was used to identify all hypotensive pediatric patients (15 years or younger) with GSWs. Hypotension was defined per Pediatric Advanced Life Support Guidelines. Patients with an Abbreviated Injury Scale score of 6 in any region and transferred patients were excluded. In order to identify the association between PTC verification status and outcomes, Poisson regression models with robust standard errors were used.
Results:
A total of 687 patients met the criteria for analysis, and 236 (34%) cases were treated at PTCs. Pediatric trauma center patients were slightly younger (lower quartile, 10 vs. 12 years old; p = 0.037). There was no significant difference in Injury Severity Score or crude mortality rates (68.1% vs. 70.8%, p = 0.524). After adjusting for confounders, Poisson regression showed no reduction in in-hospital mortality, complications, failure to rescue, intensive care unit admission, or mechanical ventilation rates at PTCs compared with ATCs.
Conclusion:
Gunshot wounds in children pose unique clinical challenges. Majority of cases are cared for at ATCs. Analysis of best available data did not demonstrate a benefit to managing these patients at a PTC. Conversely, ATCs were not superior, despite managing this scenario in both adults and children more often. These findings underscore the importance of ATCs in the care of this particular injury pattern and call attention to the recent pediatric readiness requirements for American College of Surgeons (ACS)-verified trauma centers to treat pediatric firearm injuries at both PTCs and ATC.
Level Of Evidence:
Therapeutic/Care Management; Level III.
