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Injury mechanism patterns, mortality predictors, and resource utilization in pediatric trauma in Karachi, Pakistan: A
Gauri A Lahoti1, Humera Ismail2, Divya Kewalramani1
1Division of Acute Care Surgery, Department of Surgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA.
Insights
Pediatric trauma in Pakistan, particularly from motorcycle crashes, has high mortality exceeding predictions. Strengthening trauma systems and implementing age-specific protocols are crucial for improving outcomes in young patients.
Area of Science:
- Pediatric trauma care
- Injury epidemiology
- Public health in low- and middle-income countries
Background:
- Pakistan has a high pediatric trauma burden due to its large youth population, motorcycle use, and weak traffic safety enforcement.
- Low- and middle-income countries face a disproportionate global injury burden, with limited trauma registry data.
Purpose of the Study:
- To analyze pediatric trauma injury patterns, resource utilization, and mortality in Karachi, Pakistan.
- To compare outcomes across different age groups and identify predictors of mortality.
- To benchmark observed mortality against expected mortality using the Revised Trauma Score (RTS).
Main Methods:
- Retrospective analysis of a prospectively maintained pediatric trauma registry (2018-2024; n=4576).
- Comparison of injury patterns and resource use across five age groups.
- Severity-adjusted mortality benchmarking using observed-to-expected (O:E) ratios and multivariable logistic regression for mortality predictors.
Main Results:
- Motorcycle crashes (34%), falls (33%), and pedestrian injuries (12%) were leading causes, with falls in younger children and motorcycle injuries in adolescents.
- Crude mortality was 15.1%, varying significantly by age (10.6% in 11-14 year olds to 34.9% in infants).
- Observed mortality exceeded expected mortality (O:E ratio 1.41), with higher mortality in patients requiring intensive resources and those transferred between facilities.
Conclusions:
- Pediatric trauma mortality in Karachi significantly surpasses RTS-based predictions, especially in infants.
- Findings underscore the need for trauma center regionalization, enhanced prehospital care, and age-specific resuscitation protocols.
- Systematic O:E ratio monitoring is a valuable, deployable tool for quality improvement in Pakistan's trauma system.
Background:
Pakistan faces a particularly severe pediatric trauma burden due to its large youth population, ubiquitous motorcycle use, and limited traffic safety enforcement. Low- and middle-income countries bear the vast majority of the global injury burden, yet data derived from their trauma registries remain sparse.
Methods:
We conducted a retrospective analysis of a prospectively maintained pediatric trauma registry in Karachi, Pakistan (2018-2024; n = 4576; outcomes cohort n = 3406). Injury patterns and resource utilization were compared across five age groups. Severity-adjusted mortality was benchmarked using observed-to-expected (O:E) ratios derived from the Revised Trauma Score. Multivariable logistic regression identified independent predictors of in-hospital mortality.
Results:
Of 4576 patients in the full cohort, motorcycle crashes were the most common mechanism (34%), followed by falls (33%) and pedestrian injuries (12%); falls predominated in children under 10 and motorcycle injuries in adolescents aged 11-18. Males comprised 82% overall and 93% of adolescents aged 15-18. Among 3406 patients with known disposition, crude mortality was 15.1% and varied by age group (χ²=44.1, p < 0.001), ranging from 10.6% in children aged 11-14-34.9% in infants. Resource utilization included blood transfusion (33.4%), operative intervention (20.2%), ICU admission (11.9%), and intubation (6.4%); mortality was 22.5% in high-resource-use patients (ICU admission, intubation, or operative intervention) vs. 11.4% in the remainder (p < 0.001). Among 2480 patients with calculable RTS, the O:E ratio was 1.41 (95% CI 1.27-1.57; 337 observed vs. 238 expected deaths), peaking in 2021 (2.13) and lowest in 2023 (0.77). GCS was the strongest mortality predictor (OR 0.71 per point, 95% CI 0.68-0.73); polytrauma was also associated with higher odds (aOR 2.90, 95% CI 1.13-7.43; 9 deaths among 41 cases). One-third of the full cohort arrived via inter-facility transfer (33.3%, n = 1526). After multivariable adjustment, transfer remained independently associated with higher mortality (aOR 1.88, 95% CI 1.42-2.49).
Conclusions:
Pediatric trauma mortality in Karachi greatly exceeds RTS-based predictions without anatomic adjustment, especially among the youngest patients. These findings highlight the need for trauma center regionalization, strengthened prehospital systems, and age-specific resuscitation protocols. Systematic O:E monitoring embedded within Pakistan's trauma system represents an immediately deployable quality improvement tool.
