European Journal of Cardiovascular Medicine

Trauma is a significant public health issue globally, particularly among children, who are more vulnerable due to their developmental stage and limited ability to perceive danger. According to the World Health Organization (WHO), injuries account for nearly 1 million deaths annually among children under 18 years, with millions more sustaining non-fatal injuries that often lead to long-term disability [1]. In low- and middle-income countries (LMICs), the burden of pediatric trauma is exacerbated by inadequate healthcare infrastructure, lack of preventive measures, and limited access to emergency care [2].

In India, trauma is a leading cause of pediatric morbidity and mortality, with road traffic accidents (RTAs), falls, and burns being the most common mechanisms of injury [3]. The eastern region of India, characterized by dense urban populations and rural areas with limited healthcare access, presents unique challenges in managing pediatric trauma. Understanding the patterns and outcomes of pediatric trauma in this region is essential for developing targeted interventions and improving emergency care services.

Pediatric trauma differs from adult trauma in terms of injury mechanisms, physiological responses, and outcomes. Children are more likely to sustain injuries from falls and RTAs due to their smaller size and higher levels of physical activity [4]. Additionally, the anatomical and physiological differences in children, such as a larger head-to-body ratio and thinner cranial bones, make them more susceptible to head injuries [5]. These factors underscore the need for specialized pediatric trauma care, which is often lacking in resource-limited settings.

This study aims to describe the epidemiology, clinical characteristics, and outcomes of pediatric trauma cases presenting to the emergency department (ED) of a tertiary care hospital in East India. By identifying the common mechanisms of injury, injury severity, and clinical outcomes, this study seeks to provide insights that can inform preventive strategies and improve the quality of emergency care for pediatric trauma patients

Study Design and Setting:

This was a retrospective observational study conducted in the emergency department (ED) of a tertiary care hospital in East India. The hospital is a 1,200-bed facility that serves as a referral center for both urban and rural populations in the region. The ED is equipped with advanced trauma care facilities, including a dedicated pediatric trauma bay, and handles approximately 50,000 emergency cases annually, of which 10-15% are pediatric trauma cases. The study period spanned 12 months, from January to December 2022.

Study Population:

The study included pediatric trauma patients aged 0-18 years who presented to the ED during the study period. Patients were identified through the ED registry, and their medical records were reviewed for data collection. Inclusion criteria consisted of all pediatric trauma cases with complete medical records, including demographic details, mechanism of injury, injury type, clinical management, and outcomes. Patients with incomplete records or those who left against medical advice (LAMA) were excluded from the study. A total of 90 patients met the inclusion criteria and were included in the analysis.

Data Collection:

Data were collected from the medical records of the included patients using a structured proforma. The proforma was designed to capture the following variables:

1. Demographic Details:Age, sex, and residence (urban or rural).
2. Mechanism of Injury:Falls, road traffic accidents (RTAs), burns, animal bites, penetrating injuries, and others.
3. Type of Injury:Head injuries, fractures, soft tissue injuries, abdominal injuries, thoracic injuries, and others.
4. Injury Severity:Assessed using the Pediatric Trauma Score (PTS), which evaluates six parameters: airway stability, systolic blood pressure, level of consciousness, presence of open wounds, skeletal injuries, and body weight. Each parameter is scored from -1 to +2, with a total score ranging from -6 to +12. Lower scores indicate more severe injuries.
5. Clinical Management:Conservative management (wound care, immobilization, observation), surgical intervention (fracture fixation, soft tissue repair), and advanced life support measures (intubation, mechanical ventilation).
6. Outcomes:Discharge with full recovery, hospitalization, referral to higher centers, and mortality.

Data Sources:

The primary source of data was the ED registry, which records all patient encounters, including demographic details, presenting complaints, clinical findings, and outcomes. Additional data were obtained from patient medical records, including admission notes, progress notes, discharge summaries, and operative records. For patients referred to higher centers, follow-up data were obtained from referral notes and communication with the receiving hospitals.

Data Quality Assurance:

To ensure the accuracy and completeness of the data, the following measures were implemented:

1. Training of Data Collectors:Two trained research assistants, both with a background in nursing, were responsible for data collection. They underwent a one-day training session on the study protocol, data collection tools, and ethical considerations.
2. Pilot Testing:The data collection proforma was pilot-tested on 10 medical records to identify any ambiguities or inconsistencies. Feedback from the pilot test was used to refine the proforma.
3. Data Verification:A random sample of 10% of the medical records (n=9) was cross-checked by the principal investigator to ensure the accuracy of the data collected.

Statistical Analysis:

Data were entered into Microsoft Excel and analyzed using SPSS version 25. Descriptive statistics were used to summarize the data. Continuous variables, such as age and Pediatric Trauma Score, were expressed as mean ± standard deviation (SD). Categorical variables, such as sex, mechanism of injury, type of injury, and outcomes, were expressed as frequencies and percentages. Subgroup analyses were performed to compare outcomes based on injury severity and mechanism of injury. A p-value of <0.05 was considered statistically significant.

Ethical Considerations:

The study was approved by the Institutional Ethics Committee (IEC) of the tertiary care hospital. Since the study was retrospective and involved the analysis of existing medical records, the requirement for informed consent was waived by the IEC. Patient confidentiality was maintained by anonymizing the data and using unique identification numbers instead of patient names.

Demographic Characteristics:

The study included 90 pediatric trauma patients with a mean age of 8.5 years (SD ± 4.2). The age distribution revealed that 33.3% (n=30) of the patients were aged 0-5 years, 40% (n=36) were aged 6-12 years, and 26.7% (n=24) were aged 13-18 years. Males constituted 65.6% (n=59) of the study population, while females accounted for 34.4% (n=31). The majority of patients (62.2%, n=56) were from urban areas, while 37.8% (n=34) were from rural areas.

Mechanism of Injury:

Falls were the most common mechanism of injury, accounting for 48.9% (n=44) of cases. Among these, 56.8% (n=25) were falls from heights (e.g., trees, rooftops), while 43.2% (n=19) were ground-level falls. Road traffic accidents (RTAs) were the second most common mechanism, observed in 32.2% (n=29) of cases. Of these, 55.2% (n=16) involved pedestrians, 27.6% (n=8) involved two-wheelers, and 17.2% (n=5) involved four-wheelers. Burns accounted for 10% (n=9) of cases, with 66.7% (n=6) being scalds and 33.3% (n=3) being flame burns. Other mechanisms, such as animal bites (5.6%, n=5) and penetrating injuries (3.3%, n=3), accounted for 8.9% (n=8) of cases (Table 1).

Table 1: Mechanism of Injury

Type of Injury:

Head injuries were the most common type of injury, observed in 42.2% (n=38) of patients. Among these, 63.2% (n=24) were mild traumatic brain injuries (TBIs), 26.3% (n=10) were moderate TBIs, and 10.5% (n=4) were severe TBIs. Fractures accounted for 30% (n=27) of cases, with upper limb fractures being the most frequent (55.6%, n=15), followed by lower limb fractures (33.3%, n=9) and skull fractures (11.1%, n=3). Soft tissue injuries, such as lacerations and contusions, were observed in 20% (n=18) of cases. Other injuries, including abdominal injuries (4.4%, n=4) and thoracic injuries (3.3%, n=3), accounted for 7.8% (n=7) of cases (Table 2).

Table 2: Type of Injury

Injury Severity:

The Pediatric Trauma Score (PTS) was used to assess injury severity. The mean PTS was 8.2 (SD ± 2.1), with 55.6% (n=50) of patients having a PTS of 9-12 (mild injury), 33.3% (n=30) having a PTS of 6-8 (moderate injury), and 11.1% (n=10) having a PTS of ≤5 (severe injury). Severe injuries were more common among patients involved in RTAs (60%, n=6) and falls from heights (30%, n=3).

Clinical Management:

The majority of patients (75.6%, n=68) were managed conservatively, including wound care, immobilization, and observation. Surgical intervention was required in 15.6% (n=14) of cases, primarily for fracture fixation and repair of soft tissue injuries. Advanced life support measures, such as intubation and mechanical ventilation, were required in 8.8% (n=8) of cases, all of whom had severe head injuries.

Outcomes:

The majority of patients (75.6%, n=68) were discharged with full recovery, while 15.6% (n=14) required hospitalization for further management. Of these, 57.1% (n=8) were admitted to the pediatric ward, 28.6% (n=4) to the intensive care unit (ICU), and 14.3% (n=2) to the surgical ward. Referral to higher centers for specialized care was required in 8.8% (n=8) of cases, primarily for neurosurgical and orthopedic interventions. Mortality was observed in 2.2% (n=2) of cases, both of whom had severe head injuries and multiple organ failure

The findings of this study highlight the patterns and outcomes of pediatric trauma in a tertiary care hospital in East India. The predominance of males in the study population is consistent with previous studies, which have shown that boys are more likely to sustain traumatic injuries due to higher levels of physical activity and risk-taking behavior [6]. The higher proportion of urban patients may reflect the hospital's location in an urban area, as well as better access to healthcare facilities compared to rural areas.

Falls were the most common mechanism of injury, accounting for nearly half of the cases. This is consistent with global data, which indicate that falls are a leading cause of pediatric trauma, particularly among younger children [7]. The high incidence of RTAs, particularly among older children, underscores the need for improved road safety measures, such as stricter enforcement of traffic laws and the promotion of helmet and seatbelt use [8].

Head injuries were the most frequent type of injury, reflecting the anatomical vulnerability of children to such injuries. The high mortality rate associated with severe head injuries highlights the need for early recognition and aggressive management of these cases [9]. The majority of patients achieved full recovery, which may be attributed to the availability of advanced trauma care facilities at the study hospital. However, the need for hospitalization and referral in a significant proportion of cases underscores the importance of strengthening emergency care services, particularly in resource-limited settings.

The findings of this study have several implications for public health policy and clinical practice. First, preventive measures, such as childproofing homes, promoting road safety, and raising awareness about the risks of burns, should be prioritized to reduce the incidence of pediatric trauma [10]. Second, healthcare providers should be trained in the early recognition and management of pediatric trauma, particularly head injuries, to improve outcomes. Finally, efforts should be made to improve access to emergency care services, particularly in rural areas, to ensure timely and effective treatment of pediatric trauma cases.

Limitations:

1. Retrospective Design: The study relied on existing medical records, which may have incomplete or missing data.
2. Single-Center Study: The findings may not be generalizable to other settings, particularly in rural areas with limited healthcare access.
3. Small Sample Size: The study included only 90 patients, which may limit the statistical power of the analysis.

Strengths:

1. Comprehensive Data Collection: The study captured a wide range of variables, including demographic details, mechanism of injury, injury severity, clinical management, and outcomes.
2. Use of Pediatric Trauma Score: The PTS provided a standardized measure of injury severity, allowing for meaningful comparisons across patients.
3. Focus on East India: The study contributes to the limited literature on pediatric trauma in this region, providing valuable insights for policymakers and healthcare providers.

Pediatric trauma in East India predominantly results from falls and RTAs, with head injuries being the most common. Most patients achieve full recovery, but severe cases require specialized care and have higher mortality rates. Preventive measures and improved emergency care protocols are essential to reduce the burden of pediatric trauma.

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