European Journal of Cardiovascular Medicine

Paediatric trauma represents a significant public health concern, with a substantial impact on the well-being of children worldwide. The burden of paediatric trauma is particularly pronounced in middle and low-income countries as they undergo industrialization and adopt modern lifestyles, including motorized transportation. Additionally, the presence of armed conflicts around the world involves children or innocent victims (1).

This epidemiological shift has led to an increasing incidence of injuries among children, primarily attributed to road traffic accidents, falls, assaults, and sports-related incidents. Notably, road traffic accidents and falls collectively account for more than 80% of significant injuries in this population.

 According to the data made available by the Government of India; 1,46,133 of deaths and 5,00,279 of injuries occurred due to Road traffic accidents in the year of 2015. Out of 1,46,133 persons who died in RTA 5,937 (4.1%) persons were in the age group of 0-14 years and 6,652 (4.55%) persons were between the age group of 15-17 years (2).

The response of children to trauma differs markedly from that of adults, encompassing emotional, physical, and physiological aspects. Understanding these differences is crucial for the effective management and prevention of paediatric trauma. (3). Furthermore, the etiology of paediatric trauma varies across different settings, with children in urban and rural areas facing distinct risks. For instance, children in urban areas are more susceptible to injuries from falls, while those in rural areas are often exposed to hazards related to agricultural activities and construction sites (4)

Injuries in infants and small children are frequently attributed to falls, and those with brain injuries or polytrauma experience prolonged hospital stays and higher mortality rates (5). Additionally, the cultural roles of males as breadwinners contribute to an increased likelihood of exposure to risky environments, further emphasizing the need for targeted preventive measures.

The management of paediatric trauma necessitates expert, multidisciplinary, and timely interventions to mitigate the risk of long-term morbidity and mortality (6). However, the challenges extend beyond immediate clinical care, as nosocomial infections with multidrug-resistant bacteria pose significant obstacles to trauma care, affecting the outcomes of paediatric trauma patients. Early identification of high-risk patients and infections is pivotal in preventing avoidable deaths within this vulnerable population.

This study aimed to find the incidence and the etiological causes of pediatric trauma, the utility of the diagnostic and clinical methodology and the clinical outcome of trauma patients belonging to the pediatric age group managed at our tertiary care hospital.

The prospective, observational study was conducted over one year, from 1st November 2019 to 31st October 2020. The study was conducted in the Post Graduate Department of General Surgery at GMC Jammu on 500 pediatric trauma patients selected as per the following inclusion and exclusion criteria:

Inclusion Criteria

The study included all pediatric patients up to the age of 14 admitted to the surgical units of the General Surgery Department at Govt. Medical College Jammu.

Exclusion Criteria

• Patients with an age of more than 14 years.
• Patients with burn injuries.
• Patients with isolated extremity trauma.

On admission of a trauma victim, a quick primary survey was done to identify and treat any life-threatening condition. It included ABC of trauma. The vital signs were recorded every 5 min on the monitor to detect patient progress and deterioration. Only when all ventilatory and circulatory problems were corrected (which may mean surgery), a more detailed secondary survey was conducted. In the secondary survey, a focussed history (AMPLE) was taken and a thorough head-to-toe assessment and systemic examination was performed. After the Primary survey and resuscitation, the secondary survey was done and a definitive plan of management was executed after undergoing thorough investigations. Patients were managed conservatively and surgical intervention was done as and when required. After discharge patients were followed up for three months.

Data was collected from patients, focusing on their demographics, including name, parentage, age, sex, residence, and socioeconomic status. Additionally, the study collected clinical history, including AMPLE history, mode of injury, mechanism of injury, time of accident, time of reporting, and latent period.

The study involved the analysis of various parameters, including the distribution of age, Glasgow Coma Scale, duration of hospital stays, type of residence, and FAST results. A written well-informed consent was obtained from the participants, and the study adhered to ethical guidelines for research involving human subjects.

Statistical Analysis: The recorded data was compiled and entered into a spreadsheet (Microsoft Excel) and then exported to the data editor of SPSS Version 29.0 (SPSS Inc., Chicago, Illinois, USA) and R software. Continuous variables were expressed as Mean ± SD, and categorical variables were summarized as frequencies and percentages. Graphical representation of the data was presented using bar line diagrams and pie charts. The Chi-square test or Fisher's exact test, whichever is appropriate, was applied for comparing categorical variables

In this study, 500 Pediatric trauma patients in the age group of 0-14 years admitted to the Postgraduate Department of Surgery, Government Medical College, Jammu, were included. Over one year of the study period, 3348 trauma patients were admitted to the emergency department of general surgery, out of which 500 patients, 14.93%, were paediatric patients.

In our study, the majority of paediatric patients suffering from trauma were in the age group of 1-4 years, 207(41.4%), followed by 184 (36.8%) patients in the age group of 5-9 years. A single patient was in the neonatal age group, and 14 were infants. There was male predominance in the study, with 327 (65.4%) males and 173 (34.6%) females. The ratio of males to females was approximately 3:1.

The Majority of the paediatric patients 333 (66.6%) were from rural areas and 167 (33.4%) were from urban areas          with  ratio of        rural: to urban approximately 3:1.

Table 1: Mechanism of Injury

Table 1 depicts the mechanism of injury among the study participants. In our study majority of the pediatric trauma patients had fall from height as the most common mechanism of injury accounting for 391 (78.2%) patients. It was followed by RTA accounting for 62 (12.4%) pediatric patients followed by fall of heavy objects 21(4.2%) and cycling accounting for 9 (1.8%) pediatric patients.

Fig. 1: Mechanism of injury

The majority of the patients suffered blunt trauma 487 (97.4%). Only 13 (2.6%) patients had penetrating trauma. Out of 13 patients, 10 patients had penetrating injuries over the torso. (Fig.2).

Fig. 2: Type of injury

Table 2: Distribution of organ system involved of study subjects.

Table 2 depicts the distribution of organ systems involved in study subjects. It was observed that Head injury was the most common presentation in pediatric trauma accounting for 400 (80%) pediatric patients. Abdomen was the second most isolated system involved accounting for 46 (9.2%) patients followed by facial injury accounting for 28 (5.6%) patients. Chest injuries accounted for 16 (3.2%) and Perineal/genital trauma was observed in 7 (1.4%) pediatric patients. 154 (30.8%) patients had polytrauma involving two or more than two organ systems. Thus, multisystem injuries formed the second most common injury pattern next to isolated head injuries.

Fig. 3: Organ system involved

In our study, 319 (79.75%) patients had mild head injury as per the Glasgow coma scale followed by moderate in 50 (12.5%) and severe in 31 (7.75%) patients. It shows that the majority of the patients had mild injuries and had a better prognosis. Further, FAST was done in 499 (99.8%) cases and was positive in 60 (12%) patients and negative in 439 (87.8%) pediatric trauma patients.

In our study, X-ray chest was normal in the majority of patients. NCCT Head was performed in 444 (88.8%) pediatric trauma patients with suspicion of head injury and having head injury warning signs. In 99 (19.8%) pediatric trauma patients NCCT Head was normal. Hemorrhagic contusion was the most common intracranial injury encountered in the pediatric population accounting for 87 (17.4%) pediatric head injury followed by skull fracture 82 (16.6%). EDH was seen in 57 (11.4%) pediatric trauma patients followed by SDH in 5 (10.2%). It showed facial fracture in 28 (5.6%), SAH in 22 (4.4%), and pneumocephalus in 11 (2.2%).

In our study, NCCT spine was done in 09 patients suspected of having spine injury. Out of 9 patients, 6 (66.7%) patients had normal study, only 2 (22.2%) had cervical spine trauma and 1 (11.1%) had thoracic spine trauma.

Further, out of a total of 500 patients, CECT/HRCT Chest was done in 10 chest injury patients or suspected of having chest injury and found that one (10%) patient had normal findings, 3 (30%) patients had lung contusion, 2 (20%) patients had hemothorax with a rib fracture. There were also 2 (20%) patients who were diagnosed with pneumothorax. One (10%) patient had a metallic foreign body in the chest wall and one (10%) had lung consolidation. CECT Abdomen was done in 20 patients suffering from abdominal trauma. Splenic injury was seen in 7 (35%) patients. Liver injury was seen in 5 (25%) patients with abdominal injury. 1(5%) patient had grade V kidney injury, 2 (10%) patients had hollow viscus perforation and 4 (20%) had normal scans.

In our study, the majority of the patients had a head injury 80% (n=400); out of which 370 (74.0%) head injury patients including those with associated injuries were managed conservatively whereas 29 patients (5.8%) underwent craniotomy. Out of the total of 500 patients in the series, 46 patients had abdominal trauma patients requiring laparotomy in 26 (5.2%) while the rest 20 (4.0%) patients were managed conservatively. In chest trauma 9 (1.6%) needed tube thoracostomy and 7 (1.4%) were managed conservatively. In total, 65 (13%) patients required surgical approach during management whereas a majority of 435 (87%) patients were managed conservatively.

Figure   4: Distribution of Operative management of study subjects.

Fig. 5: Conservative management

In our study, the majority of the patients had a hospital stay of fewer than 7 days, accounting for 431 (86.2%) pediatric cases. Hospital stays of 8-14 days accounted for 60 (12%) patients. Four (0.8%) patients had hospital stays of more than 21 days. 

Out of 500 patients, 25 (5.0%) patients reported complications during the treatment. Wound infection was the most common complication reported among 10 patients.

In our study, 418 (83.6%) patients recovered fully with treatment and were discharged; 22 (4.4%) pediatric trauma patients expired during the treatment period. 14 (2.8%) patients absconded from the hospital while undergoing treatment; whereas 25 (5%) trauma patients left against medical advice (LAMA). 13 (2.6%) patients were shifted to other specialties like gynecology and obstetrics and orthopedics. 4 (0.8%) were referred to higher centers for further management.

Table 3: Distribution of Probable Cause of Death.

Table 3 depicts the probable cause of death among study participants. In our study 22(4.4%) patients died. Head injury was the most common cause of mortality and was seen in 18 (81.8%) patients followed by abdominal trauma in 2 (9.1%) patients

The study examined 3,348 trauma patients treated in the hospital, of whom 500 were pediatric patients up to 14 years of age, constituting a significant proportion of the pediatric trauma caseload. Most cases were in the 1-4 years and 5-9 years age groups, aligning with previous findings from Dickinson E et al. and Coulthard MG et al (7,8). Of the 500 pediatric patients, 65.4% were male and 33.6% were female, with a male-to-female ratio of approximately 3:1, consistent with reports from Jong WJJD et al. and Meshram RJ et al (9,10).

The study observed that the maximum number of cases was 333, and a similar study by Halldorsson JG et al. found that 47% of the pediatric population was from rural areas. The predominant mechanism of injury was falls (391 cases), followed by road traffic accidents (62 cases), mirroring the findings of Poudel-Tandukar K et al. and Lalwani S et al. (11,12). The majority of injuries were blunt trauma, accounting for 97.4% of pediatric trauma patients, with the remaining 32.6% being penetrating trauma, in line with the observations of Letts M et al. and Sheehan B et al. (13,14).

The study revealed that the head was the most commonly involved system, affecting 400 cases, followed by the abdomen (46 cases) and chest (16 cases). Polytrauma was present in 154 pediatric trauma cases. These findings align with the literature, where the head is consistently reported as the most commonly involved region in pediatric trauma, as noted in the studies by Meenakshi S et al. and Coulthard MG et al. (15,16). Additionally, the majority of patients sustained mild head injuries, with 12.5% experiencing moderate and 7.75% severe head injuries, similar to the results reported by Meshram RJ et al. in their study on 'Risk factors of pediatric head injury' (17).

In our study, 46 patients experienced abdominal injuries. Additionally, 16 patients sustained chest injuries, with 8 patients having multiple rib fractures, 4 experiencing pneumothorax, and 4 presenting with hemothorax. These findings align with the studies conducted by Stafford PW et al., and Avarello JT (18,19).

Out of 9 pediatric trauma patients who underwent NCCT spine evaluation due to suspected spinal injury, 6 had normal studies, 2 had cervical spine trauma, and 1 had thoracic spine trauma. Although spinal cord injury is relatively uncommon in the pediatric population, cervical spine injury must be presumed until proven otherwise.

In the current study, focused assessment with sonography in trauma was performed on 499 patients, and the test was positive in 60 pediatric trauma patients, while negative in 439. These results are consistent with the study conducted by Soudack M et al.(20).

Our study reported splenic injury in 7 patients, liver injuries in 5 patients, hollow viscus injury in 2 patients, and 1 renal injury in a trauma patient. In contrast, Hassan R et al. found liver, spleen, and renal injuries in 42.1%, 34.9%, and 30.0% of cases, respectively (21).

The study found that 435 out of 500 patients were managed conservatively, while only 65 required operative intervention. Additionally, the study observed that the majority of patients, 80%, had sustained head injuries. Of these, 370 patients, including those with associated injuries, were managed conservatively, while 29 patients underwent craniotomy. Regarding abdominal injuries, 26 out of a total of 46 patients required laparotomy, while the remaining 20 were managed conservatively. These findings align with the study conducted by Wisner DH et al.(22).

In cases of chest trauma, 9 patients required tube thoracostomy, while 7 were managed conservatively. The present study found that 87% of patients were managed conservatively and were discharged within 7 days, without necessitating prolonged hospital stays. These findings align with the study conducted by Teuben M et al. (23).

Furthermore, the study reported 22 patient deaths, with head injuries being the predominant cause. The overall mortality rate was 4.4%. Notably, the outcomes between conservatively and operatively managed patients did not demonstrate statistically significant differences. These results are consistent with the studies by Aoki M et al., and Bahloul M et al.(24,25).

The present study provides a comprehensive analysis of the epidemiology, clinical patterns, and management approaches for pediatric trauma patients treated at a major trauma center. The findings reinforce the importance of a multidisciplinary approach to pediatric trauma management, emphasizing the role of conservative management strategies whenever feasible.

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