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In-hospital mortality pattern of severely injured children
Injury, Int. J. Care Injured 43 (2012) 2060–2064
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In-hospital mortality pattern of severely injured children§ Hien Quoc Do a,b,*, Jacob Steinmetz a,b, Lars S. Rasmussen a a b
Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Trauma Centre, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 6 December 2011
Background: Although trauma remains a major cause of morbidity and mortality in children, less attention has been directed to this group of patients. Whilst there is considerable literature on trauma in adults, only few studies describe paediatric trauma. The aim of this study was to describe the mortality pattern of severely injured children admitted to a Danish level I trauma centre. Methods: We included trauma patients aged 15 years or less, who subsequent a trauma team activation were admitted during the 9-year period 1999–2007. Data were collected prospectively for subjects who had a length of stay 72 h, were admitted to the intensive care unit (regardless of length of stay), or died in hospital. Logistic regression analysis was performed to assess independent predictors for in-hospital mortality. p < 0.05 was considered statistically significant. Results: We included 331 patients, 199 (60.1%) boys/132 girls with a median age of 7 years and injury severity score (ISS) of 9. A total of 307/331 (92.7%) survived to discharge, and 16/24 (66.7%) deaths occurred within 24 h after admission. Age was significantly lower in patients dying due to trauma (median 5 (0–15) vs. 7 (0–15) years, p = 0.04, adjusted odds ratio (OR) = 0.89 [95% CI: 0.80–0.99]). ISS was significantly higher in patients who died (median 25 (16–71) vs. 9 (4–29), p < 0.0001, adjusted OR = 1.15 [95% CI: 1.10–1.20]). Conclusions: Children who did not survive after severe trauma were significantly younger, more injured, and died early after admission. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Children Injury Mortality Paediatric Trauma
Introduction According to the Trauma Audit and Research Network (TARN), children represent around 10% of all trauma admissions.1 Although trauma remains a major cause of morbidity and mortality in children, less attention has been directed to this group of patients.2 Whilst there is considerable literature on trauma in adults, only few studies describe paediatric trauma.3 The condition of an injured child may deteriorate rapidly, and appropriate initial assessment and resuscitation are therefore essential for a good outcome.4 Paediatric trauma should accordingly be handled by specially trained personnel. Although the principles of resuscitation of injured children are similar to adults, several anatomic and physiologic differences must be appreciated.5 In
§ Presented at the 31st Congress of The Scandinavian Society of Anaesthesiology and Intensive Care Medicine, 15–17 June 2011, Bergen, Norway, the 5th London Trauma Conference, 22–24 June 2011, London, United Kingdom, and the Annual Meeting of The Danish Society of Anaesthesiology and Intensive Care Medicine, 10– 12 November 2011, Copenhagen, Denmark, with abstracts published in the conference proceedings. * Corresponding author at: Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. Tel.: +45 35453360. E-mail address: [email protected] (H.Q. Do).
0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.12.005
addition, common injuries and their unique characteristics in terms of severity, needs, and outcome should be recognised. Nevertheless, few resources have been directed to this, and moreover, existing studies mainly describe patients from the United States, and children in selected groups, e.g. polytrauma, those who required intensive care, or died.6 Thus, identification of injury and mortality patterns in paediatric trauma patients in general may improve the knowledge of children admitted with severe trauma. European studies on paediatric trauma are currently available from the United Kingdom, Germany, Finland, Norway, amongst others.6–9 However, none have described paediatric trauma patients from Denmark. Heterogeneous eligibility criteria inevitably lead to different trauma patterns, thereby causing diverse interpretations.10 Studies from different trauma settings are therefore necessitated to elucidate similarities and differences country-wise. The aim of this study was to describe the mortality pattern of severely injured children admitted to a Danish level I trauma centre. Materials and methods Study design Trauma patients aged 15 years or less admitted to the Trauma Centre of Copenhagen University Hospital, Rigshospitalet (TCCUH)
H.Q. Do et al. / Injury, Int. J. Care Injured 43 (2012) 2060–2064
during the 9-year period January 1st 1999 to December 31st 2007 were eligible for inclusion if the trauma team was activated. TCCUH is the only designated level I trauma centre in Eastern Denmark, it constitutes a national burn centre, and comprises approximately 2.5 million citizens. Data were collected prospectively for subjects who had a total length of stay 72 h, were admitted to the intensive care unit (ICU) (regardless of length of stay), were secondarily referred from other hospitals, or died in hospital. Children without confirmed injuries, or those who survived with only minor injuries and were discharged after a brief observation were excluded, i.e. uncomplicated limb injuries, closed facial injuries, simple skin injuries, and burns less than 10% of total body surface area. We recorded demographic information, route of admission (primary vs. secondary referral), injury pattern, length of stay (total and ICU), and outcome data. Injury Severity Score (ISS) and probability of survival (Ps) were obtained from TARN. Ps was calculated using the TARN Outcome Prediction Model (Ps09), based on age, gender, Glasgow Coma Scale score (GCS), and ISS.11 Subjects were studied with regard to in-hospital mortality, and in four age groups (<1 year, 1–5 years, 6–10 years, and 11–15 years). Injury patterns were grouped as type (blunt, penetrating, and burn), and mechanism (falls, road traffic accident (RTA), blast, blow, burn, shooting, stabbing, and other). A follow-up analysis was performed to determine long-term survival status. Patients with foreign nationality and patients who emigrated were censored in this analysis. On March 1st 2011, we obtained vital status for eligible patients through the Danish Civil Registration System by means of their unique Personal Identification Number.12
Results During the study period, 331 paediatric trauma patients were included. There was no significant change in annual admission rate (p = 0.97). We included 199 (60.1%) boys and 132 girls with a median age of 7 (0–15) years and ISS of 9 (4–37). Severe injury, defined as ISS > 15, was present in 118 (35.6%) patients. Overall Ps was 99% (52–100). 203 (61.3%) were secondarily transferred to TCCUH from another hospital. There was no significant change in route of admission over the study period (p = 0.96). We did not find any significant differences in patient demographics (age, gender, and ISS) according to route of admission. Blunt trauma was the most frequent type (66.8%), followed by burns (30.5%), and penetrating trauma (2.7%). Length of stay in total and in the ICU were 10 (1–40) and 0 (0–8) days, respectively. Analysis by mortality A total of 307/331 (92.7% [95% CI: 89.4–95.1]) patients survived to discharge (Table 1). Long-term survival status was unaccounted for in 20 patients due to either foreign nationality or emigration. Of the remaining 287 patients who survived to discharge, only one (0.3%) was dead at follow-up. The patient had a history of suicide attempts and died 11 months after discharge. Eligible patients were followed-up for a median of 7.6 (3.5–11.7) years.
Table 1 Characteristics of 331 paediatric trauma patients with regard to in-hospital mortality.
Outcome Our primary end-point was in-hospital mortality in severely injured children. Secondary end-points were analysis by age groups, length of stay in the ICU, and long-term survival. Statistics Continuous data are reported as medians with 5–95% percentiles, whilst categorical data are reported as counts with percentages (%). Continuous variables were contrasted with Kruskal–Wallis-test or Wilcoxon rank-sum-test where appropriate, whilst categorical variables were compared with x2-test. Change in annual admission rate was assessed with Poisson regression. Stepwise logistic regression analysis with backward selection was performed to assess independent predictors for in-hospital mortality. The following covariates were included in this analysis: age, gender, ISS, and route of admission. p < 0.05 was considered statistically significant. Moreover, in-hospital mortality was analysed according to probability of survival. Patients with Ps > 75% or Ps < 25% were eligible for review by HQD and JAS. Unexpected death was defined as Ps > 75% in patients who died, whilst unexpected survival was defined as Ps < 25% in patients who survived. The analyses were performed using SPSS Statistics 18.0 (SPSS Inc., Chicago, IL). Ethics Permission from the Danish Data Protection Agency has been obtained for the database. According to Danish law, neither informed consent from patients, nor approval from the Ethics Committee were required.
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Patient demographics Age (years) Male gender Injury Severity Score 15 >15 Probability of survival (%)a Route of admission Primary triage to trauma centre Secondary transfer from local hospital Type Blunt Penetrating Burn Mechanism Falls >2 m <2 m Road traffic accident Car accident Cyclist/pedestrian Motorcyclist/moped Blast Blow Burn Shooting Stabbing Other Blunt/penetrating Length of stay (days) Total ICU Long-term survivalb
Patients who survived to discharge, n = 307
Patients who died in hospital, n = 24
7 (0–15) 184 (59.9) 9 (4–29) 213 (69.4) 94 (30.6) 99 (71–100)
5 (0–15) 15 (62.5) 25 (16–71) 0 (0.0) 24 (100.0) 57 (21–96)
121 (39.4) 186 (60.6)
7 (29.2) 17 (70.8)
204 (66.4) 8 (2.6) 95 (30.9)
17 (70.8) 1 (4.2) 6 (25.0)
80 (26.0) 63 (20.5) 17 (5.5) 102 (33.2) 23 (7.5) 62 (20.2) 17 (5.5) 5 (1.6) 13 (4.2) 95 (30.9) 1 (0.3) 3 (1.0) 8 (2.6) 6/2
4 (16.7) 3 (12.5) 1 (4.2) 13 (54.2) 4 (16.7) 9 (37.5) 0 (0.0) 0 (0.0) 0 (0.0) 6 (25.0) 0 (0.0) 1 (4.2) 0 (0.0) 0/0
11 (3–42) 0 (0–8) 286/287
1 (0–22) 1 (0–22) –
Data are reported as medians with (5–95% percentiles) or counts with (%). a The probability of survival was unknown in 39 cases (11.8%). b Long-term survival status was unaccounted for in 20/307 patients (6.5%) due to foreign nationality or emigration.
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Table 2 Logistic regression analysis on predictors of in-hospital mortality after paediatric trauma (n = 331). Predictors of in-hospital mortality
Unadjusted odds ratio (95% CI)
p
Adjusted odds ratio (95% CI)
p
Age (year) Gender (male) Injury Severity Score (per unit) Triage (primary referral)
0.96 1.11 1.14 0.63
0.32 0.81 <0.0001 0.32
0.89 (0.80–0.99) N/A 1.15 (1.10–1.20) N/A
0.04 N/A <0.0001 N/A
(0.89–1.04) (0.47–2.63) (1.09–1.18) (0.26–1.57)
Data are given as odds ratios with 95% confidence intervals (CI). p < 0.05 was considered statistically significant.
Blunt trauma was the most frequent cause of death, and RTAs accounted for more than half of these cases. One-fourth died from burns, and finally one died from penetrating trauma. Patients died early after admission, and death within 24 h after admission occurred in 16/24 (66.7%) patients. Only two patients were hospitalised for more than one week, 9 and 26 days, respectively. Logistic regression analysis revealed that age and ISS were significantly associated with in-hospital mortality in the adjusted analysis (Table 2). Age was significantly lower in patients dying due to trauma (median 5 (0–15) vs. 7 (0–15) years, p = 0.04, adjusted odds ratio (OR) = 0.89 [95% CI: 0.80–0.99]). ISS was significantly higher in patients who died (median 25 (16–71) vs. 9 (4–29), p < 0.0001, adjusted OR = 1.15 [95% CI: 1.10–1.20]). There were no significant differences in gender or route of admission between patients who survived and died. Ps was lower in patients who actually died (median Ps 57% (21– 96) vs. 99% (71–100) in survivors). Unexpected death was observed in six patients having a Ps > 75% (range: 80–96%). Their ISS were in range 17–25. Two patients had prehospital GCS scores of 7 and 10, respectively, whilst GCS scores were not recorded for the remaining four patients. Four patients died of blunt trauma, whilst two suffered from significant burns. All six patients were
males and secondarily transferred to TCCUH. Only one patient had a Ps < 25% (Ps = 17%). This patient was involved in a RTA, had an ISS of 59, and did not survive to discharge. No unexpected survival was therefore observed (survival in spite of Ps < 25%). Analysis by age groups Injury type and mechanism were significantly different amongst the four age groups (p < 0.0001) (Table 3). Burns were the leading cause of trauma in children aged less than 1 year, whilst burns and blunt trauma occurred at a similar frequency in 1–5 year old children. Children older than 6 years were more often implicated in blunt trauma, predominantly RTAs and falls. This age-related difference in injury pattern was reflected in the total length of stay that decreased with advancing age (p = 0.005). The proportion of male gender, and ISS increased with age, however not significantly. The age groups did not differ with regard to route of admission. Discussion In this study we found that young age and high ISS were independent factors significantly associated with in-hospital
Table 3 Age-related differences in patient demographics, route of admission, injury pattern, and hospital stay amongst 331 paediatric trauma patients.
Patient demographics Age (years) Male gender Injury Severity Score 15 >15 Route of admission Primary triage to trauma centre Secondary transfer from local hospital Type Blunt Penetrating Burn Mechanism Falls >2 m <2 m Road traffic accident Car accident Cyclist/pedestrian Motorcyclist/moped Blast Blow Burn Shooting Stabbing Other Blunt/penetrating Length of stay (days) Total ICU Survival to discharge
<1 year
1–5 years
6–10 years
11–15 years
n = 20
n = 119
n = 72
n = 120
0 (0–0) 9 (45.0) 9 (4–40) 15 (75.0) 5 (25.0)
2 (1–5) 64 (53.8) 9 (4–35) 80 (67.2) 39 (32.8)
8 (6–10) 48 (66.7) 10 (4–37) 45 (62.5) 27 (37.5)
14 78 11 73 47
8 (40.0) 12 (60.0)
52 (43.7) 67 (56.3)
22 (30.6) 50 (69.4)
46 (38.3) 74 (61.7)
7 (35.0) 0 (0.0) 13 (65.0)
58 (48.7) 3 (2.5) 58 (48.7)
58 (80.6) 1 (1.4) 13 (18.1)
98 (81.7) 5 (4.2) 17 (14.2)
3 (15.0) 2 (10.0) 1 (5.0) 4 (20.0) 3 (15.0) 1 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 13 (65.0) 0 (0.0) 0 (0.0) 0 (0.0) 0/0
36 (30.3) 26 (21.8) 10 (8.4) 19 (16.0) 5 (4.2) 14 (11.8) 0 (0.0) 0 (0.0) 3 (2.5) 58 (48.7) 0 (0.0) 1 (0.8) 2 (1.7) 1/1
18 (25.0) 14 (19.4) 4 (5.6) 31 (43.1) 4 (5.6) 26 (36.1) 1 (1.4) 2 (2.8) 6 (8.3) 13 (18.1) 0 (0.0) 0 (0.0) 2 (2.8) 2/0
27 (22.5) 24 (20.0) 3 (2.5) 61 (50.8) 15 (12.5) 30 (25.0) 16 (13.3) 3 (2.5) 4 (3.3) 17 (14.2) 1 (0.8) 3 (2.5) 4 (3.3) 3/1
20 (1–36) 0 (0–2) 19 (95.0)
15 (1–43) 0 (0–9) 107 (89.9)
9 (2–62) 1 (0–10) 68 (94.4)
9 (1–41) 1 (0–8) 113 (94.2)
(11–15) (65.0) (4–41) (60.8) (39.2)
p
0.10 0.19
0.35
< 0.0001
< 0.0001
0.005 0.002
Data are reported as medians with (5–95 percentiles) or proportions with (%). Differences between age groups were assessed with either x2-test or Kruskal–Wallis test.
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mortality in severely injured children. We also found that traumarelated death in children usually occurred early after admission. Finally, we found important age-related differences in injury pattern. It is a strength that no significant change in admission rate and route of admission occurred during the study period. Furthermore, the present study provides a high quality of survival data, as 93.5% of eligible patients were followed-up for more than 7 years. Several limitations must be taken into consideration. This study is based on data from one specific country, as we aimed to report mortality data for paediatric trauma patients from Denmark. Although this data only represents a single institution, TCCUH is distinguished by comprising nearly half of the Danish population. However, we recognise that our results may not be completely representative. Furthermore, our trauma organisation may likely differ from those of other countries, thus impeding generalisability. Due to the nature of the study, we cannot be sure that all paediatric trauma patients were included. First, some patients may mistakenly have been misclassified as non-trauma patients, despite thorough record review. Second, the cohort reflects our trauma centre as a tertiary care facility; hence some children probably died immediately on scene, or at the local hospital, and were brought directly to the Institute of Forensic Medicine, thus bypassing TCCUH. This number might in fact be considerable.8,9 Hence, our results do not include all paediatric trauma patients in the region. However, as no central registration of trauma patients exists, we could not control for possible missing patients. Furthermore, it is a limitation that we did not account for any interventions or possible changes in treatment protocol during the study period. In addition, the injury and mortality patterns depicted in this study may to some extent be explained by triage in the prehospital setting and the great extent of secondary transfers. On the other hand, it reflects a tertiary care hospital reasonably well. It is also important to realise that we only described the patients with regard to survival, and not the longterm disabilities or quality of life.13,14 Mere survival is, however, a suitable endpoint for identifying injury and mortality patterns, and thus, the acute trauma care. Finally, we acknowledge that our results must be interpreted in context of the eligibility criteria. By this selection we chose to focus mainly on severely injured children. Our results are therefore not widely applicable to all paediatric trauma patients. As a consequence of a large amount of missing data, especially vital signs, probability of survival was not determined using the TRISS method (Trauma and Injury Severity Score).15 Instead, Ps was utilised with the TARN model.11 Although this model is not widely used, it was preferable with an estimate on survival, since no control group was available. Nevertheless, the TARN model has shown similar or even superior discriminant abilities with regard to survival prediction in comparison to TRISS.11,16 Also, TARN methodology has several advantages over TRISS. First, the use of GCS instead of the revised trauma score (a weighted combination of GCS, systolic blood pressure, and respiratory rate) in TARN reduces the significant number of cases excluded due to missing data in TRISS (namely respiratory rate) – in line with our data. In addition, the original TRISS model is derived from adult trauma patients, excluding children, burns, and interhospital transfers, basically constituting our cohort. Whilst different models for these subgroups of trauma patients have arisen from TRISS, TARN includes all subgroups in one single model. Finally, TARN and TRISS use statistical coefficients based on European and US patients, respectively, thereby representing different trauma patterns. Application of the TARN model to our data was therefore considered appropriate. Six deceased patients had rather high Ps, although the ISS corresponded to severe trauma. A review of these patients revealed
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that they were in fact severely injured. The calculation of Ps-scores with TARN methodology are highly dependent of the initially measured GCS score.11 Hence, a high or a missing GCS results in a large probability of survival, with the latter being somewhat inaccurate. Although a few patients were outliers, in general, the Psscores contributed positively to the assessment of the trauma care. We were surprised to find that children who died after paediatric trauma were significantly younger than those who survived. There may be several explanations for this finding. First, our finding may be attributable to a selection bias in terms of prehospital triage. Bias is introduced, as severely injured children are admitted directly to TCCUH by protocol, whilst less injured children are transferred to local hospitals. Inconsistencies in demographic data between patients staying at the local hospital and patients eventually transferred to TCCUH might be apparent, and should accordingly have been addressed. Second, younger children are more vulnerable to physical trauma in comparison to older children, as they have larger heads and less protection of viscera by bones and musculature. A recent study showed that the incidence of head injury in infants was almost twice that of older children, and moreover, that head injury in fact was the predominant cause of death.6 Furthermore, this study found, that death after abdominal injury was significantly higher in children less than 5 years. Hence, the impact and severity of trauma may be greater in young children. Third, young children may be more difficult to diagnose and treat. Diversity in terms of anatomy and physiologic response makes interpretation of clinical signs challenging. In addition, personnel may be less prone to expose young children to radiation due to an considerable lifetime risk of cancer,17 thus resulting in delayed diagnosis and thereby specific treatment. Finally, given the low number of events, our finding may be a chance finding. The findings should accordingly be treated with caution, and the rather high pvalue for age in the univariate analysis is in theory compatible with a type 1 error arisen from multiple testing. Other studies conducted on selected populations of paediatric trauma have shown similar tendencies with regard to young age and in-hospital mortality.9,18–20 Due to different study designs and statistical approaches, our results are not comparable. Nevertheless, these findings call for further investigation on this age-related difference in mortality, and future prospective studies should focus on elucidating possible explanations. Such efforts might in fact reduce mortality in young children.21 We suggest that future studies approach this study’s limitations by enhancing collaboration with prehospital organisations, local hospitals, and forensics; thus reducing selection bias by allowing review of all relevant patients including prehospital deaths. Furthermore, injury patterns should be analysed according to Abbreviated Injury Scale to elucidate high-risk injuries across age groups.6 It would also be beneficial to assess diagnostics and treatment to reveal any agerelated differences. Finally, the low incidence of severe paediatric traumas mandates larger, multicenter studies; ideally through existing trauma networks, such as TARN. In this study children seemed to die early after admission. This pattern is consistent with a bimodal death distribution shown in other studies.9,22 In comparison to a trimodal death curve in adults, death after trauma in children appears to follow a bimodal curve. The initial peak in this bimodal distribution represents patients dying immediately after the incident owing to unsalvageable injuries. A second peak appears a short while after the incident, and its magnitude depend on prehospital care and triage to an appropriate trauma centre, and obviously the care given at the trauma facility. To reduce the magnitude of this second peak, efforts should accordingly be made to identify these patients in the prehospital setting. Fortunately, only one patient was dead at follow-up. As this death occurred several months after discharge, it is unlikely that it can be explained by the trauma. Hence, the decision of discharging
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a child after trauma seems to be well founded. Furthermore, the follow-up analysis shows that none died after discharge following child abuse. This might have been feared, given the extent of child abuse in high-income countries.23 Our findings on injury patterns are somewhat similar to those depicted by the World Health Organization and other European studies.2,6–9 However, in this study we observed a relatively larger proportion of children suffering from burns. This is explained by the fact that TCCUH constitutes a national burn centre. Although the observed injury patterns may not seem surprising, it is important to emphasise these differences in terms of preventive measures. Such interventions may consist of raised awareness, education, legislation, and environmental changes.2,24,25 This is the first study on paediatric trauma patients in Denmark. It provides important information on severely injured children with regard to injury and mortality patterns. This may hopefully facilitate a better trauma organisation, and thereby improve the treatment and caretaking of children admitted with severe trauma. Conclusions We conclude that children who did not survive after severe trauma were significantly younger, more injured, and died early after admission. Conflict of interest We declare that we have no conflict of interests. Acknowledgements We thank Jan Olsen and Vibeke U. Dahl for significant help with the trauma registry. No financial support was received for this study. References 1. Trauma Audit & Research Network. Quarterly Report II 2011: Orthopaedic Injuries, http://www.tarn.ac.uk/. 2. World Health Organization. World report on child injury prevention, http:// www.who.int/violence_injury_prevention/child/injury/world_report/en/ 3. Upperman JS, Burd R, Cox C, Ehrlich P, Mooney D, Groner JI. Pediatric applied trauma research network: a call to action. J Trauma 2010;69:1304–7.
4. Knudson MM, McGrath J. Improving outcomes in pediatric trauma care: essential characteristics of the trauma center. J Trauma 2007;63:S140–2. 5. American College of Surgeons Committee on Trauma. ATLS1 for doctors student manual with DVD. 8th ed. Chicago: American College of Surgeons Committee on Trauma; 2008. 6. Bayreuther J, Wagener S, Woodford M, Edwards A, Lecky F, Bouamra O, et al. Paediatric trauma: injury pattern and mortality in the UK. Arch Dis Child Educ Pract Ed 2009;94:37–41. 7. Buschmann C, Kuhne CA, Losch C, Nast-Kolb D, Ruchholtz S. Major trauma with multiple injuries in German children: a retrospective review. J Pediatr Orthop 2008;28:1–5. 8. Søreide K, Kruger AJ, Ellingsen CL, Tjosevik KE. Pediatric trauma deaths are predominated by severe head injuries during spring and summer. Scand J Trauma Resusc Emerg Med 2009;17:3. 9. Suominen P, Kivioja A, Ohman J, Korpela R, Rintala R, Olkkola KT. Severe and fatal childhood trauma. Injury 1998;29:425–30. 10. Bergeron E, Lavoie A, Moore L, Bamvita JM, Ratte S, Clas D. Paying the price of excluding patients from a trauma registry. J Trauma 2006;60:300–4. 11. Bouamra O, Wrotchford A, Hollis S, Vail A, Woodford M, Lecky F. A new approach to outcome prediction in trauma: a comparison with the TRISS model. J Trauma 2006;61:701–10. 12. Frank L. Epidemiology. When an entire country is a cohort. Science 2000;287: 2398–9. 13. Winthrop AL, Brasel KJ, Stahovic L, Paulson J, Schneeberger B, Kuhn EM. Quality of life and functional outcome after pediatric trauma. J Trauma 2005;58:468–73. [discussion 73–4]. 14. Polinder S, Meerding WJ, Toet H, Mulder S, Essink-Bot ML, van Beeck EF. Prevalence and prognostic factors of disability after childhood injury. Pediatrics 2005;116:e810–7. 15. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method, Trauma Score and the Injury Severity Score. J Trauma 1987;27:370–8. 16. de Jongh MA, Verhofstad MH, Leenen LP. Accuracy of different survival prediction models in a trauma population. Br J Surg 2010;97:1805–13. 17. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176:289–96. 18. Burd RS, Jang TS, Nair SS. Evaluation of the relationship between mechanism of injury and outcome in pediatric trauma. J Trauma 2007;62:1004–14. 19. Javouhey E, Guerin AC, Amoros E, Haddak M, Ndiaye A, Floret D, et al. Severe outcome of children following trauma resulting from road accidents. Eur J Pediatr 2006;165:519–25. 20. Morrow SE, Smith DL, Cairns BA, Howell PD, Nakayama DK, Peterson HD. Etiology and outcome of pediatric burns. J Pediatr Surg 1996;31:329–33. 21. Sheridan RL, Remensnyder JP, Schnitzer JJ, Schulz JT, Ryan CM, Tompkins RG. Current expectations for survival in pediatric burns. Arch Pediatr Adolesc Med 2000;154:245–9. 22. Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Guzzetta PC, Anderson KD, et al. Patterns of injury in children. J Pediatr Surg 1990;25:85–90. [discussion 90–91]. 23. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;373: 68–81. 24. Dowd MD, Keenan HT, Bratton SL. Epidemiology and prevention of childhood injuries. Crit Care Med 2002;30:S385–92. 25. Shields BJ, Smith GA. Success in the prevention of infant walker-related injuries: an analysis of national data, 1990–2001. Pediatrics 2006;117:e452–9.
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In-hospital mortality pattern of severely injured children§ Hien Quoc Do a,b,*, Jacob Steinmetz a,b, Lars S. Rasmussen a a b
Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Trauma Centre, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 6 December 2011
Background: Although trauma remains a major cause of morbidity and mortality in children, less attention has been directed to this group of patients. Whilst there is considerable literature on trauma in adults, only few studies describe paediatric trauma. The aim of this study was to describe the mortality pattern of severely injured children admitted to a Danish level I trauma centre. Methods: We included trauma patients aged 15 years or less, who subsequent a trauma team activation were admitted during the 9-year period 1999–2007. Data were collected prospectively for subjects who had a length of stay 72 h, were admitted to the intensive care unit (regardless of length of stay), or died in hospital. Logistic regression analysis was performed to assess independent predictors for in-hospital mortality. p < 0.05 was considered statistically significant. Results: We included 331 patients, 199 (60.1%) boys/132 girls with a median age of 7 years and injury severity score (ISS) of 9. A total of 307/331 (92.7%) survived to discharge, and 16/24 (66.7%) deaths occurred within 24 h after admission. Age was significantly lower in patients dying due to trauma (median 5 (0–15) vs. 7 (0–15) years, p = 0.04, adjusted odds ratio (OR) = 0.89 [95% CI: 0.80–0.99]). ISS was significantly higher in patients who died (median 25 (16–71) vs. 9 (4–29), p < 0.0001, adjusted OR = 1.15 [95% CI: 1.10–1.20]). Conclusions: Children who did not survive after severe trauma were significantly younger, more injured, and died early after admission. ß 2011 Elsevier Ltd. All rights reserved.
Keywords: Children Injury Mortality Paediatric Trauma
Introduction According to the Trauma Audit and Research Network (TARN), children represent around 10% of all trauma admissions.1 Although trauma remains a major cause of morbidity and mortality in children, less attention has been directed to this group of patients.2 Whilst there is considerable literature on trauma in adults, only few studies describe paediatric trauma.3 The condition of an injured child may deteriorate rapidly, and appropriate initial assessment and resuscitation are therefore essential for a good outcome.4 Paediatric trauma should accordingly be handled by specially trained personnel. Although the principles of resuscitation of injured children are similar to adults, several anatomic and physiologic differences must be appreciated.5 In
§ Presented at the 31st Congress of The Scandinavian Society of Anaesthesiology and Intensive Care Medicine, 15–17 June 2011, Bergen, Norway, the 5th London Trauma Conference, 22–24 June 2011, London, United Kingdom, and the Annual Meeting of The Danish Society of Anaesthesiology and Intensive Care Medicine, 10– 12 November 2011, Copenhagen, Denmark, with abstracts published in the conference proceedings. * Corresponding author at: Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark. Tel.: +45 35453360. E-mail address: [email protected] (H.Q. Do).
0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2011.12.005
addition, common injuries and their unique characteristics in terms of severity, needs, and outcome should be recognised. Nevertheless, few resources have been directed to this, and moreover, existing studies mainly describe patients from the United States, and children in selected groups, e.g. polytrauma, those who required intensive care, or died.6 Thus, identification of injury and mortality patterns in paediatric trauma patients in general may improve the knowledge of children admitted with severe trauma. European studies on paediatric trauma are currently available from the United Kingdom, Germany, Finland, Norway, amongst others.6–9 However, none have described paediatric trauma patients from Denmark. Heterogeneous eligibility criteria inevitably lead to different trauma patterns, thereby causing diverse interpretations.10 Studies from different trauma settings are therefore necessitated to elucidate similarities and differences country-wise. The aim of this study was to describe the mortality pattern of severely injured children admitted to a Danish level I trauma centre. Materials and methods Study design Trauma patients aged 15 years or less admitted to the Trauma Centre of Copenhagen University Hospital, Rigshospitalet (TCCUH)
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during the 9-year period January 1st 1999 to December 31st 2007 were eligible for inclusion if the trauma team was activated. TCCUH is the only designated level I trauma centre in Eastern Denmark, it constitutes a national burn centre, and comprises approximately 2.5 million citizens. Data were collected prospectively for subjects who had a total length of stay 72 h, were admitted to the intensive care unit (ICU) (regardless of length of stay), were secondarily referred from other hospitals, or died in hospital. Children without confirmed injuries, or those who survived with only minor injuries and were discharged after a brief observation were excluded, i.e. uncomplicated limb injuries, closed facial injuries, simple skin injuries, and burns less than 10% of total body surface area. We recorded demographic information, route of admission (primary vs. secondary referral), injury pattern, length of stay (total and ICU), and outcome data. Injury Severity Score (ISS) and probability of survival (Ps) were obtained from TARN. Ps was calculated using the TARN Outcome Prediction Model (Ps09), based on age, gender, Glasgow Coma Scale score (GCS), and ISS.11 Subjects were studied with regard to in-hospital mortality, and in four age groups (<1 year, 1–5 years, 6–10 years, and 11–15 years). Injury patterns were grouped as type (blunt, penetrating, and burn), and mechanism (falls, road traffic accident (RTA), blast, blow, burn, shooting, stabbing, and other). A follow-up analysis was performed to determine long-term survival status. Patients with foreign nationality and patients who emigrated were censored in this analysis. On March 1st 2011, we obtained vital status for eligible patients through the Danish Civil Registration System by means of their unique Personal Identification Number.12
Results During the study period, 331 paediatric trauma patients were included. There was no significant change in annual admission rate (p = 0.97). We included 199 (60.1%) boys and 132 girls with a median age of 7 (0–15) years and ISS of 9 (4–37). Severe injury, defined as ISS > 15, was present in 118 (35.6%) patients. Overall Ps was 99% (52–100). 203 (61.3%) were secondarily transferred to TCCUH from another hospital. There was no significant change in route of admission over the study period (p = 0.96). We did not find any significant differences in patient demographics (age, gender, and ISS) according to route of admission. Blunt trauma was the most frequent type (66.8%), followed by burns (30.5%), and penetrating trauma (2.7%). Length of stay in total and in the ICU were 10 (1–40) and 0 (0–8) days, respectively. Analysis by mortality A total of 307/331 (92.7% [95% CI: 89.4–95.1]) patients survived to discharge (Table 1). Long-term survival status was unaccounted for in 20 patients due to either foreign nationality or emigration. Of the remaining 287 patients who survived to discharge, only one (0.3%) was dead at follow-up. The patient had a history of suicide attempts and died 11 months after discharge. Eligible patients were followed-up for a median of 7.6 (3.5–11.7) years.
Table 1 Characteristics of 331 paediatric trauma patients with regard to in-hospital mortality.
Outcome Our primary end-point was in-hospital mortality in severely injured children. Secondary end-points were analysis by age groups, length of stay in the ICU, and long-term survival. Statistics Continuous data are reported as medians with 5–95% percentiles, whilst categorical data are reported as counts with percentages (%). Continuous variables were contrasted with Kruskal–Wallis-test or Wilcoxon rank-sum-test where appropriate, whilst categorical variables were compared with x2-test. Change in annual admission rate was assessed with Poisson regression. Stepwise logistic regression analysis with backward selection was performed to assess independent predictors for in-hospital mortality. The following covariates were included in this analysis: age, gender, ISS, and route of admission. p < 0.05 was considered statistically significant. Moreover, in-hospital mortality was analysed according to probability of survival. Patients with Ps > 75% or Ps < 25% were eligible for review by HQD and JAS. Unexpected death was defined as Ps > 75% in patients who died, whilst unexpected survival was defined as Ps < 25% in patients who survived. The analyses were performed using SPSS Statistics 18.0 (SPSS Inc., Chicago, IL). Ethics Permission from the Danish Data Protection Agency has been obtained for the database. According to Danish law, neither informed consent from patients, nor approval from the Ethics Committee were required.
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Patient demographics Age (years) Male gender Injury Severity Score 15 >15 Probability of survival (%)a Route of admission Primary triage to trauma centre Secondary transfer from local hospital Type Blunt Penetrating Burn Mechanism Falls >2 m <2 m Road traffic accident Car accident Cyclist/pedestrian Motorcyclist/moped Blast Blow Burn Shooting Stabbing Other Blunt/penetrating Length of stay (days) Total ICU Long-term survivalb
Patients who survived to discharge, n = 307
Patients who died in hospital, n = 24
7 (0–15) 184 (59.9) 9 (4–29) 213 (69.4) 94 (30.6) 99 (71–100)
5 (0–15) 15 (62.5) 25 (16–71) 0 (0.0) 24 (100.0) 57 (21–96)
121 (39.4) 186 (60.6)
7 (29.2) 17 (70.8)
204 (66.4) 8 (2.6) 95 (30.9)
17 (70.8) 1 (4.2) 6 (25.0)
80 (26.0) 63 (20.5) 17 (5.5) 102 (33.2) 23 (7.5) 62 (20.2) 17 (5.5) 5 (1.6) 13 (4.2) 95 (30.9) 1 (0.3) 3 (1.0) 8 (2.6) 6/2
4 (16.7) 3 (12.5) 1 (4.2) 13 (54.2) 4 (16.7) 9 (37.5) 0 (0.0) 0 (0.0) 0 (0.0) 6 (25.0) 0 (0.0) 1 (4.2) 0 (0.0) 0/0
11 (3–42) 0 (0–8) 286/287
1 (0–22) 1 (0–22) –
Data are reported as medians with (5–95% percentiles) or counts with (%). a The probability of survival was unknown in 39 cases (11.8%). b Long-term survival status was unaccounted for in 20/307 patients (6.5%) due to foreign nationality or emigration.
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Table 2 Logistic regression analysis on predictors of in-hospital mortality after paediatric trauma (n = 331). Predictors of in-hospital mortality
Unadjusted odds ratio (95% CI)
p
Adjusted odds ratio (95% CI)
p
Age (year) Gender (male) Injury Severity Score (per unit) Triage (primary referral)
0.96 1.11 1.14 0.63
0.32 0.81 <0.0001 0.32
0.89 (0.80–0.99) N/A 1.15 (1.10–1.20) N/A
0.04 N/A <0.0001 N/A
(0.89–1.04) (0.47–2.63) (1.09–1.18) (0.26–1.57)
Data are given as odds ratios with 95% confidence intervals (CI). p < 0.05 was considered statistically significant.
Blunt trauma was the most frequent cause of death, and RTAs accounted for more than half of these cases. One-fourth died from burns, and finally one died from penetrating trauma. Patients died early after admission, and death within 24 h after admission occurred in 16/24 (66.7%) patients. Only two patients were hospitalised for more than one week, 9 and 26 days, respectively. Logistic regression analysis revealed that age and ISS were significantly associated with in-hospital mortality in the adjusted analysis (Table 2). Age was significantly lower in patients dying due to trauma (median 5 (0–15) vs. 7 (0–15) years, p = 0.04, adjusted odds ratio (OR) = 0.89 [95% CI: 0.80–0.99]). ISS was significantly higher in patients who died (median 25 (16–71) vs. 9 (4–29), p < 0.0001, adjusted OR = 1.15 [95% CI: 1.10–1.20]). There were no significant differences in gender or route of admission between patients who survived and died. Ps was lower in patients who actually died (median Ps 57% (21– 96) vs. 99% (71–100) in survivors). Unexpected death was observed in six patients having a Ps > 75% (range: 80–96%). Their ISS were in range 17–25. Two patients had prehospital GCS scores of 7 and 10, respectively, whilst GCS scores were not recorded for the remaining four patients. Four patients died of blunt trauma, whilst two suffered from significant burns. All six patients were
males and secondarily transferred to TCCUH. Only one patient had a Ps < 25% (Ps = 17%). This patient was involved in a RTA, had an ISS of 59, and did not survive to discharge. No unexpected survival was therefore observed (survival in spite of Ps < 25%). Analysis by age groups Injury type and mechanism were significantly different amongst the four age groups (p < 0.0001) (Table 3). Burns were the leading cause of trauma in children aged less than 1 year, whilst burns and blunt trauma occurred at a similar frequency in 1–5 year old children. Children older than 6 years were more often implicated in blunt trauma, predominantly RTAs and falls. This age-related difference in injury pattern was reflected in the total length of stay that decreased with advancing age (p = 0.005). The proportion of male gender, and ISS increased with age, however not significantly. The age groups did not differ with regard to route of admission. Discussion In this study we found that young age and high ISS were independent factors significantly associated with in-hospital
Table 3 Age-related differences in patient demographics, route of admission, injury pattern, and hospital stay amongst 331 paediatric trauma patients.
Patient demographics Age (years) Male gender Injury Severity Score 15 >15 Route of admission Primary triage to trauma centre Secondary transfer from local hospital Type Blunt Penetrating Burn Mechanism Falls >2 m <2 m Road traffic accident Car accident Cyclist/pedestrian Motorcyclist/moped Blast Blow Burn Shooting Stabbing Other Blunt/penetrating Length of stay (days) Total ICU Survival to discharge
<1 year
1–5 years
6–10 years
11–15 years
n = 20
n = 119
n = 72
n = 120
0 (0–0) 9 (45.0) 9 (4–40) 15 (75.0) 5 (25.0)
2 (1–5) 64 (53.8) 9 (4–35) 80 (67.2) 39 (32.8)
8 (6–10) 48 (66.7) 10 (4–37) 45 (62.5) 27 (37.5)
14 78 11 73 47
8 (40.0) 12 (60.0)
52 (43.7) 67 (56.3)
22 (30.6) 50 (69.4)
46 (38.3) 74 (61.7)
7 (35.0) 0 (0.0) 13 (65.0)
58 (48.7) 3 (2.5) 58 (48.7)
58 (80.6) 1 (1.4) 13 (18.1)
98 (81.7) 5 (4.2) 17 (14.2)
3 (15.0) 2 (10.0) 1 (5.0) 4 (20.0) 3 (15.0) 1 (5.0) 0 (0.0) 0 (0.0) 0 (0.0) 13 (65.0) 0 (0.0) 0 (0.0) 0 (0.0) 0/0
36 (30.3) 26 (21.8) 10 (8.4) 19 (16.0) 5 (4.2) 14 (11.8) 0 (0.0) 0 (0.0) 3 (2.5) 58 (48.7) 0 (0.0) 1 (0.8) 2 (1.7) 1/1
18 (25.0) 14 (19.4) 4 (5.6) 31 (43.1) 4 (5.6) 26 (36.1) 1 (1.4) 2 (2.8) 6 (8.3) 13 (18.1) 0 (0.0) 0 (0.0) 2 (2.8) 2/0
27 (22.5) 24 (20.0) 3 (2.5) 61 (50.8) 15 (12.5) 30 (25.0) 16 (13.3) 3 (2.5) 4 (3.3) 17 (14.2) 1 (0.8) 3 (2.5) 4 (3.3) 3/1
20 (1–36) 0 (0–2) 19 (95.0)
15 (1–43) 0 (0–9) 107 (89.9)
9 (2–62) 1 (0–10) 68 (94.4)
9 (1–41) 1 (0–8) 113 (94.2)
(11–15) (65.0) (4–41) (60.8) (39.2)
p
0.10 0.19
0.35
< 0.0001
< 0.0001
0.005 0.002
Data are reported as medians with (5–95 percentiles) or proportions with (%). Differences between age groups were assessed with either x2-test or Kruskal–Wallis test.
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mortality in severely injured children. We also found that traumarelated death in children usually occurred early after admission. Finally, we found important age-related differences in injury pattern. It is a strength that no significant change in admission rate and route of admission occurred during the study period. Furthermore, the present study provides a high quality of survival data, as 93.5% of eligible patients were followed-up for more than 7 years. Several limitations must be taken into consideration. This study is based on data from one specific country, as we aimed to report mortality data for paediatric trauma patients from Denmark. Although this data only represents a single institution, TCCUH is distinguished by comprising nearly half of the Danish population. However, we recognise that our results may not be completely representative. Furthermore, our trauma organisation may likely differ from those of other countries, thus impeding generalisability. Due to the nature of the study, we cannot be sure that all paediatric trauma patients were included. First, some patients may mistakenly have been misclassified as non-trauma patients, despite thorough record review. Second, the cohort reflects our trauma centre as a tertiary care facility; hence some children probably died immediately on scene, or at the local hospital, and were brought directly to the Institute of Forensic Medicine, thus bypassing TCCUH. This number might in fact be considerable.8,9 Hence, our results do not include all paediatric trauma patients in the region. However, as no central registration of trauma patients exists, we could not control for possible missing patients. Furthermore, it is a limitation that we did not account for any interventions or possible changes in treatment protocol during the study period. In addition, the injury and mortality patterns depicted in this study may to some extent be explained by triage in the prehospital setting and the great extent of secondary transfers. On the other hand, it reflects a tertiary care hospital reasonably well. It is also important to realise that we only described the patients with regard to survival, and not the longterm disabilities or quality of life.13,14 Mere survival is, however, a suitable endpoint for identifying injury and mortality patterns, and thus, the acute trauma care. Finally, we acknowledge that our results must be interpreted in context of the eligibility criteria. By this selection we chose to focus mainly on severely injured children. Our results are therefore not widely applicable to all paediatric trauma patients. As a consequence of a large amount of missing data, especially vital signs, probability of survival was not determined using the TRISS method (Trauma and Injury Severity Score).15 Instead, Ps was utilised with the TARN model.11 Although this model is not widely used, it was preferable with an estimate on survival, since no control group was available. Nevertheless, the TARN model has shown similar or even superior discriminant abilities with regard to survival prediction in comparison to TRISS.11,16 Also, TARN methodology has several advantages over TRISS. First, the use of GCS instead of the revised trauma score (a weighted combination of GCS, systolic blood pressure, and respiratory rate) in TARN reduces the significant number of cases excluded due to missing data in TRISS (namely respiratory rate) – in line with our data. In addition, the original TRISS model is derived from adult trauma patients, excluding children, burns, and interhospital transfers, basically constituting our cohort. Whilst different models for these subgroups of trauma patients have arisen from TRISS, TARN includes all subgroups in one single model. Finally, TARN and TRISS use statistical coefficients based on European and US patients, respectively, thereby representing different trauma patterns. Application of the TARN model to our data was therefore considered appropriate. Six deceased patients had rather high Ps, although the ISS corresponded to severe trauma. A review of these patients revealed
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that they were in fact severely injured. The calculation of Ps-scores with TARN methodology are highly dependent of the initially measured GCS score.11 Hence, a high or a missing GCS results in a large probability of survival, with the latter being somewhat inaccurate. Although a few patients were outliers, in general, the Psscores contributed positively to the assessment of the trauma care. We were surprised to find that children who died after paediatric trauma were significantly younger than those who survived. There may be several explanations for this finding. First, our finding may be attributable to a selection bias in terms of prehospital triage. Bias is introduced, as severely injured children are admitted directly to TCCUH by protocol, whilst less injured children are transferred to local hospitals. Inconsistencies in demographic data between patients staying at the local hospital and patients eventually transferred to TCCUH might be apparent, and should accordingly have been addressed. Second, younger children are more vulnerable to physical trauma in comparison to older children, as they have larger heads and less protection of viscera by bones and musculature. A recent study showed that the incidence of head injury in infants was almost twice that of older children, and moreover, that head injury in fact was the predominant cause of death.6 Furthermore, this study found, that death after abdominal injury was significantly higher in children less than 5 years. Hence, the impact and severity of trauma may be greater in young children. Third, young children may be more difficult to diagnose and treat. Diversity in terms of anatomy and physiologic response makes interpretation of clinical signs challenging. In addition, personnel may be less prone to expose young children to radiation due to an considerable lifetime risk of cancer,17 thus resulting in delayed diagnosis and thereby specific treatment. Finally, given the low number of events, our finding may be a chance finding. The findings should accordingly be treated with caution, and the rather high pvalue for age in the univariate analysis is in theory compatible with a type 1 error arisen from multiple testing. Other studies conducted on selected populations of paediatric trauma have shown similar tendencies with regard to young age and in-hospital mortality.9,18–20 Due to different study designs and statistical approaches, our results are not comparable. Nevertheless, these findings call for further investigation on this age-related difference in mortality, and future prospective studies should focus on elucidating possible explanations. Such efforts might in fact reduce mortality in young children.21 We suggest that future studies approach this study’s limitations by enhancing collaboration with prehospital organisations, local hospitals, and forensics; thus reducing selection bias by allowing review of all relevant patients including prehospital deaths. Furthermore, injury patterns should be analysed according to Abbreviated Injury Scale to elucidate high-risk injuries across age groups.6 It would also be beneficial to assess diagnostics and treatment to reveal any agerelated differences. Finally, the low incidence of severe paediatric traumas mandates larger, multicenter studies; ideally through existing trauma networks, such as TARN. In this study children seemed to die early after admission. This pattern is consistent with a bimodal death distribution shown in other studies.9,22 In comparison to a trimodal death curve in adults, death after trauma in children appears to follow a bimodal curve. The initial peak in this bimodal distribution represents patients dying immediately after the incident owing to unsalvageable injuries. A second peak appears a short while after the incident, and its magnitude depend on prehospital care and triage to an appropriate trauma centre, and obviously the care given at the trauma facility. To reduce the magnitude of this second peak, efforts should accordingly be made to identify these patients in the prehospital setting. Fortunately, only one patient was dead at follow-up. As this death occurred several months after discharge, it is unlikely that it can be explained by the trauma. Hence, the decision of discharging
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a child after trauma seems to be well founded. Furthermore, the follow-up analysis shows that none died after discharge following child abuse. This might have been feared, given the extent of child abuse in high-income countries.23 Our findings on injury patterns are somewhat similar to those depicted by the World Health Organization and other European studies.2,6–9 However, in this study we observed a relatively larger proportion of children suffering from burns. This is explained by the fact that TCCUH constitutes a national burn centre. Although the observed injury patterns may not seem surprising, it is important to emphasise these differences in terms of preventive measures. Such interventions may consist of raised awareness, education, legislation, and environmental changes.2,24,25 This is the first study on paediatric trauma patients in Denmark. It provides important information on severely injured children with regard to injury and mortality patterns. This may hopefully facilitate a better trauma organisation, and thereby improve the treatment and caretaking of children admitted with severe trauma. Conclusions We conclude that children who did not survive after severe trauma were significantly younger, more injured, and died early after admission. Conflict of interest We declare that we have no conflict of interests. Acknowledgements We thank Jan Olsen and Vibeke U. Dahl for significant help with the trauma registry. No financial support was received for this study. References 1. Trauma Audit & Research Network. Quarterly Report II 2011: Orthopaedic Injuries, http://www.tarn.ac.uk/. 2. World Health Organization. World report on child injury prevention, http:// www.who.int/violence_injury_prevention/child/injury/world_report/en/ 3. Upperman JS, Burd R, Cox C, Ehrlich P, Mooney D, Groner JI. Pediatric applied trauma research network: a call to action. J Trauma 2010;69:1304–7.
4. Knudson MM, McGrath J. Improving outcomes in pediatric trauma care: essential characteristics of the trauma center. J Trauma 2007;63:S140–2. 5. American College of Surgeons Committee on Trauma. ATLS1 for doctors student manual with DVD. 8th ed. Chicago: American College of Surgeons Committee on Trauma; 2008. 6. Bayreuther J, Wagener S, Woodford M, Edwards A, Lecky F, Bouamra O, et al. Paediatric trauma: injury pattern and mortality in the UK. Arch Dis Child Educ Pract Ed 2009;94:37–41. 7. Buschmann C, Kuhne CA, Losch C, Nast-Kolb D, Ruchholtz S. Major trauma with multiple injuries in German children: a retrospective review. J Pediatr Orthop 2008;28:1–5. 8. Søreide K, Kruger AJ, Ellingsen CL, Tjosevik KE. Pediatric trauma deaths are predominated by severe head injuries during spring and summer. Scand J Trauma Resusc Emerg Med 2009;17:3. 9. Suominen P, Kivioja A, Ohman J, Korpela R, Rintala R, Olkkola KT. Severe and fatal childhood trauma. Injury 1998;29:425–30. 10. Bergeron E, Lavoie A, Moore L, Bamvita JM, Ratte S, Clas D. Paying the price of excluding patients from a trauma registry. J Trauma 2006;60:300–4. 11. Bouamra O, Wrotchford A, Hollis S, Vail A, Woodford M, Lecky F. A new approach to outcome prediction in trauma: a comparison with the TRISS model. J Trauma 2006;61:701–10. 12. Frank L. Epidemiology. When an entire country is a cohort. Science 2000;287: 2398–9. 13. Winthrop AL, Brasel KJ, Stahovic L, Paulson J, Schneeberger B, Kuhn EM. Quality of life and functional outcome after pediatric trauma. J Trauma 2005;58:468–73. [discussion 73–4]. 14. Polinder S, Meerding WJ, Toet H, Mulder S, Essink-Bot ML, van Beeck EF. Prevalence and prognostic factors of disability after childhood injury. Pediatrics 2005;116:e810–7. 15. Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method, Trauma Score and the Injury Severity Score. J Trauma 1987;27:370–8. 16. de Jongh MA, Verhofstad MH, Leenen LP. Accuracy of different survival prediction models in a trauma population. Br J Surg 2010;97:1805–13. 17. Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol 2001;176:289–96. 18. Burd RS, Jang TS, Nair SS. Evaluation of the relationship between mechanism of injury and outcome in pediatric trauma. J Trauma 2007;62:1004–14. 19. Javouhey E, Guerin AC, Amoros E, Haddak M, Ndiaye A, Floret D, et al. Severe outcome of children following trauma resulting from road accidents. Eur J Pediatr 2006;165:519–25. 20. Morrow SE, Smith DL, Cairns BA, Howell PD, Nakayama DK, Peterson HD. Etiology and outcome of pediatric burns. J Pediatr Surg 1996;31:329–33. 21. Sheridan RL, Remensnyder JP, Schnitzer JJ, Schulz JT, Ryan CM, Tompkins RG. Current expectations for survival in pediatric burns. Arch Pediatr Adolesc Med 2000;154:245–9. 22. Peclet MH, Newman KD, Eichelberger MR, Gotschall CS, Guzzetta PC, Anderson KD, et al. Patterns of injury in children. J Pediatr Surg 1990;25:85–90. [discussion 90–91]. 23. Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;373: 68–81. 24. Dowd MD, Keenan HT, Bratton SL. Epidemiology and prevention of childhood injuries. Crit Care Med 2002;30:S385–92. 25. Shields BJ, Smith GA. Success in the prevention of infant walker-related injuries: an analysis of national data, 1990–2001. Pediatrics 2006;117:e452–9.