- Email: [email protected]
Preventable traumatic deaths in children
P r e v e n t a b l e T r a u m a t i c D e a t h s in C h i l d r e n By Charlotte McKoy and Martin J. Bell St. Louis, M i s s o u r i 9 In order to discern the frequency of preventable traumatic deaths in children, the medical examiners' records of 118 consecutive traumatic deaths (except burns and drownings) in children up to 15 years of age in metropolitan St. Louis w e r e reviewed between 1977 and 1981. Thirty-eight different hospitals were involved in the case of these patients. W h e r e possible, victims w e r e assigned a Modified Injury Severity Score (MISS). Twenty-five percent of the deaths unassociated w i t h neurological damage w e r e deemed preventable. The frequency of preventable deaths and the excessive number of hospitals involved suggests that pediatric surgeons should become involved in the development of regionalized trauma care, lending their expertise to the development of triage and treatment protocols for injured children. INDEX WORDS: Traumatic death, pediatric.
R A U M A is the leading cause of death in the pediatric age group, with major injuries accounting for more than half of the deaths in children 14 years and younger.14 The specialized nature of appropriate management of the multiple-trauma patient has been supported by several studies, T M among them a study by West and Trunkey. 12 In 1974 they reviewed the death certificates of 100 consecutive adults who died after having been in automobile accidents. They excluded all patients dead at the scene and all who died primarily as a result of central nervous system injuries. The purpose of the study was to compare the results of management of severe trauma in two California counties, one of which referred patients to a trauma center, and one which referred patients to the hospital nearest the scene of the injury. A second-stage study, in which detailed hospital records were reviewed, confirmed the initial conclusion that a significant number of deaths could have been avoided with more optimal management. With the initiation of a trauma-center program, there is now strong evidence that their conclusion was valid.~3 Stimulated by these studies in the adult population, we reviewed a series of deaths due to injury in metropolitan St. Louis, Missouri, in chidren under the age of 15 years. Our objective was to provide a data base from which to initiate a review of the quality of care available to the
T
Journal of Pediatric Surgery, Vol. 18, No. 4 (August), 1983
pediatric trauma patient in our area where trauma-center designation and triage have yet to be developed. MATERIAL AND METHODS Using the records of the Medical Examiners' Offices of the city of St. Louis and St. Louis County, we reviewed 118 consecutive trauma deaths (excluding drownings and burns) in children 15 years or younger during a 5-year period from 1977 to 1981. Although this time period reflects the documentation of records by a medical examiner rather than a coroner, the content of these records varied from as little as the death certificate and police records to more detailed hospital and autopsy reports. Patients dead at the scene or on arrival were excluded. The mechanism of injury, age, sex, and race were recorded. Diagnostic procedures, consulted services, details of resuscitation, and the type and timing of operation were noted when possible. Also reviewed were transport times, referrals to secondary hospitals, and the time interval between arrival at the ultimate hospital and death. The survival times were calculated based upon information on the death certificate which recorded time of injury and the time of death. Where information allowed, neurologic injury was graded by the Glasgow Coma Scale with conversion to the Modified Injury Severity Scale (MISS) as previously described. ] Injuries to other body areas were graded according to the MISS. In the 86 (73%) patients to whom we were able to assign a MISS score, we reviewed a subset of 59 patients whose score of 40 or less suggested a greater possibility of survival with optimal care.
RESULTS
The mechanisms of injury were: vehicularpedestrian 41%; vehicular-passenger 30%; gunshot wounds 13%; falls 8%, and other 8%. The latter 8% included beatings, a plane crash, a van-train collision, and crush injuries from falling objects. Most of the deaths (42%) involved the age group 11 to 15 years, followed in
From the Washington University School of Medicine and the St. Louis Children's Hospital, Department of Pediatric Surgery, St. Louis, Mo. Presented before the 31st Annual Meeting of the Surgical Section of the American Academy of Pediatrics, New York, New York, October 23-24, 1982. Address reprint requests to Martin J. Bell, MD, 500 South Kingshighway, St. Louis, MO 63110. 9 1983 by Grune & Stratton, Inc. 0022-3468/83/1804-0033/$01.00/0 505
506
frequency by 2 to 5 years (29%), 6 to 10 years (17%), 7 to 24 months (9%), a n d n e w b o r n to 6 months (3%). Fifty percent involved white males, 24% involved white females, 20% involved black males, a n d 6% involved black females. Forty-two percent of the patients were initially seen in 23 hospitals a n d were s u b s e q u e n t l y referred to 15 different hospitals where they received their definitive care a n d then died. T h e r e m a i n i n g 58% were a d m i t t e d and died without transfer in the initial hospital to which they were transported. In all, 38 hospitals were involved in the care of the 118 patients over a 5-year period. T r a n s p o r t time from the site of i n j u r y to either the initial or definitive hospital were available in only 31% of the patients reviewed. O f these, 38% required less t h a n 20 minutes, and 30% took more t h a n 30 minutes. I n f o r m a t i o n concerning the type and t i m i n g of operation were not available in 65% of the cases. O f the r e m a i n i n g 42 patients, 39 patients u n d e r w e n t operative procedure. Details of the t i m i n g a n d conduct of operation were i n a d e q u a t e for further study. Seven percent of the injured children died within one hour of injury, 29% died within four hours, 40% died within 12 hours, and 52% died within the first 24 hours. T h i r t y - o n e percent of the deaths occurred from 1 to 6 days, and 17% died more t h a n one week post injury. T h e time of arrival at the hospital until the time of death was u n k n o w n in 52% of the cases. Six percent died within 30 m i n u t e s of arrival, and 35% died within four hours of arrival. Forty-seven percent of all 118 patients studied sustained nervous system i n j u r y only. Thirty-six percent combined neurological and other body part injuries, a n d 17% had injuries not associated with the nervous system. A M I S S score could be calculated in 86 of the patients. O f these, 9% had scores of less t h a n 25, a n d 69% had scores less t h a n 40. In those patients with a M I S S of less than 40, neurological i n j u r y alone was present in 23 (39%), neurological i n j u r y was combined with other i n j u r y in 19 (32%), a n d non-neurological injuries accounted for 17 (29%). O f the 20 patients whose injuries did not involve the central nervous system, five (25%) were considered, on the basis of available records, to have been preventable deaths. Four of these patients had a M I S S score of 25 or less.
MCKOY AND BELL
CASE REPORTS Case 1 (MISS 25) A 14-year-oldmale sustained a gunshot wound to the right chest. He arrived at the hospital 15 minutes after injury and was observed. One hour later, he "deteriorated and stabilized" with crystaloid administration. Two and one half hours after injury, he again deteriorated with findings of right pleural fluid requiring a chest tube and intubation. He could not be resuscitated, and expired without operation three hours and 20 minutes after arriving at the hospital. Autopsy revealed laceration of the right atrium, pulmonary artery, and pulmonary vein. Comment. Although this patient was ultimately found to have a grave injury, a higher index of suspicion for injury to the mediastinal structures should have dictated a more aggressive diagnostic effort and management of his initial period of deterioration. His exsanguination 11/2hours later, without thoracotomy, represents failure to appreciate the serious nature of the wound.
Case 2 (MISS 25) A 2-year-old male was referred to a second hospital for further evaluation. In the emergency room he had a respiratory rate of 40, pulse of 130, and a temperature of 101.4. No blood pressure was recorded. He was described as lethargic, and multiple areas of ecchymosis on his anterior abdominal wall were noted. X-rays and spinal fluid were obtained, a peripheral IV was established, and the child was observed in the emergency room. He expired three hours later without operation. An autopsy revealed a torn small-bowelmesentery and massive intraabdominal and retroperitoneal bleeding. Comment. A more appropriate assessment of this child with external evidenceof blunt abdominal trauma and recognition of a hypoperfused state would have allowed earlier diagnosis and intervention. Although lethargy and fever may have suggested meningitis, a negative tap should have focused attention on the abdomen.
Case 3 (MISS 43) A 15-year-oldmale was thrown from a van, seen at a local hospital, and referred. He was noted to have bilateral ribfractures, fractured processes of T 12, L 1-3, and right pleural fluid. He had an IVP which was normal and a negative liver-spleen scan. He was admitted, transfused, held NPO, given intravenous fluidsand analgesics,and observed. He was tachycardic and persistently complained of abdominal pain. He became confused and combative at 19 hours post injury. Greater than 24 hours after injury, a right chest tube was placed, obtaining 1000 cc of blood. A central venous catheter (CVC) was placed, with readings of 0 to 3 cm of water 33 hours after admission. An upper-gastrointestinal series revealed a small-bowel perforation. The patient arrested shortly before being taken to the operating room, and could not be resuscitated. Autopsy revealed a subscapular hematoma of the liver, a 1 cm tear of the proximaljejunum with a mesenteric tear, a retroperitoneal hematoma, and peritonitis.
PREVENTABLE TRAUMATICDEATHS Comment. With evidence of significant trauma to the chest (rib fractures and right pleural fluid), earlier placement of a chest tube and careful serial monitoring of arterial blood gases appear to have been indicated. Multiple transverse process fractures and possible ileus would dictate early decompression by nasogastric tube. Use of analgesics may have confused the physical findings, but persistent tachycardia, a confused, combative state, and complaint of abdominal pain suggested the need for careful review of the state of oxygenation and possible unrecognized abdominal injury.
Case 4 (MISS 16) A 2-year-old male sustained blunt abdominal trauma, was seen at a local hospital, and referred. On admission the patient was noted to have a systolic blood pressure of 66 and pulse rate of 192, and was sent to the x-ray department. Four hours later he had a systolic blood pressure of 78 and a pulse of 200. At five hours, he became bradycardic. After a cutdown for venous access was done, a peritoneal lavage revealed bloody return. He underwent exploratory laparotomy with findings of subscapular hematoma of the liver with right adrenal and perinephric hematoma. He continued to deteriorate after operation, and died eight hours later. Comment. This markedly taehycardic child was observed for over three hours without intravenous access or apparent recognition of marginal hemodynamics while prolonged radiographic studies were performed. Case 5 (MISS 9) An 11-year-old male sustained a gunshot wound to the right lower leg while hunting. He was seen at a local hospital where he was given intravenous crystalloid, and referred. He arrived at the definitive hospital alert and oriented with a blood pressure of 100 and pulse of 180. Hematocrit of 5 and hemoglobin of 1 were noted. He was given an additional 2 liters of D5LR and 25 g of albumin. Taken to the operating room one hour after his arrival, he arrested just prior to the induction of anesthesia, and could not be resuscitated. He received the first transfusion of blood in the operating room concomitant with his arrest. Comment. A delay in transfusion (with unmatched O negative blood) appears to account for this patient's preventable death. DISCUSSION D e v e l o p m e n t o f an efficient, effective s y s t e m o f t r a u m a c a r e involves highly o r g a n i z e d , specially t r a i n e d personnel including t r a n s p o r t a t i o n teams, technologists, nurses, a n d physicians who have r e p e a t e d exposure to severely i n j u r e d patients. T r e u f e l and T r u n k e y s t a t e d t h a t an effective t r a u m a p r o g r a m should see a p p r o x i m a t e l y 400 critically injured patients per year. x2 O f the 118 patients studied, 42% were seen at local hospitals and s u b s e q u e n t l y referred to 15 different hospitals. A total o f 38 different hospi-
507 tals were involved in the c a r e o f 118 p a t i e n t s over a 5-year period; an a v e r a g e o f 0.6 patients per hospital per year. It is p r e s u m e d t h a t a similar n u m b e r of hospitals were involved in the c a r e of n o n - f a t a l injuries. E x p e r t c a r e is not likely to develop in such low f r e q u e n c y situations. Conc e n t r a t i n g the c r i t i c a l l y i n u j u r e d patients in regional centers would allow i m p r o v e d experience by highly t r a i n e d individuals at all levels a n d would allow even b e t t e r utilization of existing resources. A t the u l t i m a t e hospital (ie, t h e hospital in which the p a t i e n t received the m a j o r portion of the c a r e a n d s u b s e q u e n t l y expired) the services most frequently consulted were n e u r o s u r g e r y , followed by g e n e r a l s u r g e r y a n d orthopedics. Diagnostic studies most f r e q u e n t l y used were plain r o e n t g e n o g r a m s a n d C T scans. W h e t h e r or not these consultants and d i a g n o s t i c studies were i m m e d i a t e l y a v a i l a b l e is not known from the records reviewed. R e c o g n i z i n g the need for a simple, s t a n d a r d scale which codes the severity o f injury as well as the a n a t o m i c a l location, we elected to use the Modified I n j u r y S e v e r i t y Scale, as published by M a y e r et a l ) J4 This scale has been well docum e n t e d in l a r g e r series of a d u l t patients as an effective tool to c o m p a r e m u l t i p l e injuries, morbidity, a n d m o r t a l i t y . 8't5:6 It provides a basis of c o m p a r i s o n a m o n g patients with m u l t i p l e injuries g r a d e d by other scales a n d m a n a g e d in a v a r i e t y of institutions. A M I S S code could be assigned to 73% ( 8 6 / 118) of the p a t i e n t s reviewed. A w a r e o f the subjective aspects of t h e scoring system, we d i d not assign a score when d a t a were not a d e q u a t e or the m a g n i t u d e of "the injury was unclear. W e assigned a lower score in instances of controversy. O u r use of the scale, therefore, underestim a t e s the severity of injury in q u e s t i o n a b l e cases. R e c o g n i z i n g our l i m i t a t i o n of source by using only the m e d i c a l e x a m i n e r s ' records, we were d i s t u r b e d by the l a c k of objective d a t a a v a i l a b l e even when relatively c o m p l e t e hospital records were included. M u c h i n f o r m a t i o n necessary for periodic review of t h e d e t a i l e d m a n a g e m e n t of a c u t e l y injured patients was absent. I n f o r m a t i o n p e r t a i n i n g to t r a n s p o r t a t i o n a n d resuscitation, a n d to the t i m i n g a n d c o n d u c t of the o p e r a t i o n
508
MCKOY AND BELL
were u n a v a i l a b l e in 69%, 58%, a n d 65% respectively. T h e use of a t r a u m a registry would provide a data base allowing objective, ongoing assessment of t r a u m a m a n a g e m e n t . 17 This is vital i n f o r m a t i o n for a n y productive evaluation of patient care a n d distribution. Five patients of 118 were deemed preventable deaths. Significantly, none of the five had a n y central nervous system injury. In all five patients, there was considerable delay after arrival at the hospital in the recognition of the extent of i n j u r y a n d in the institution of appropriate therapy. This delay occurred in c o m m u n i t y hospitals as well as in university hospital systems which theoretically had the capability of supporting m a j o r t r a u m a t i c injuries. O u r i d e n t i f i c a t i o n of p r e v e n t a b l e d e a t h s emphasizes the need for active participation of pediatric surgeons in the development of orga-
nized t r a u m a care for the pediatric patient. This includes efficient transport teams (capable of resuscitation and support) with centralization of care to reduce the n u m b e r of hospitals involved and allow a broader experience by those capable of providing full support to critically injured patients. This would necessitate the systematic, detailed recording of d a t a in a t r a u m a registry, facilitating periodic critical review of p a t i e n t distribution and m a n a g e m e n t . This also includes education of the public a n d f u n d i n g for more efficient, effective m a n a g e m e n t of the injured pediatric patient. ACKNOWLEDGMENT
We wish to acknowledge the generous cooperation of Dr George E. Gantner, Chief Medical Examiner, and Dr Mary E. Case, Deputy Chief Medical Examiner, of St. Louis City and County.
REFERENCES
1. Mayer T, Matlak ME, Johnson DG, et al: The modified injury severity scale in pediatric multiple trauma patients. J Pediatr Surg 15:719-726, 1980 2. Izant RJ Jr, Hnbay CA: The annual injury of 15,000,000 children: A limited study of childhood accident injury and death. J Trauma 6:65-74, 1966 3. Gratz RR: Accidental injury in childhood: A literature review on pediatric trauma. J Trauma 19:551-555, 1979 4. Trunkey DD: Society of University Surgeons. Presidential address: On the nature of things that go bang in the night. Surgery 92:123-132, 1982 5. Boyd DR: A symposium on the Illinois Trauma Program: A systems approach to the care of the critically injured. J Trauma 13:275-284, 1973 6. Frey CF, Huelke DF, Gikas PW: Resuscitation and survival in motor vehicle accidents. J Trauma 9:292-310, 1960 7. Detmer DE, Moylan JA, Rose J, et al: Regional categorization and quality of care in major trauma. J Trauma 17:592-599, 1977 8. Moylan JA, Detmer DE, RoseJ, et al: Evaluation of the quality of hospital care for major trauma. J Trauma 16:517523, 1976 9. Gertner HR Jr, Baker SP, Rutherford RB, et al:
Evaluation of the management of vehicular fatalities secondary to abdominal injury. J Trauma 12:425--431, 1972 10. Waters JM Jr, Wells CH: The effects of a modern emergencymedical care system in reducing automobile crash deaths. J Trauma 13:645-647, 1973 11. Gill W, Champion HR, Long WB, et al: A clinical experience of major multiple trauma in Maryland. Md State Med J 25:55-58, 1976 12. West JG, Trunkey DD, Lim RC: Systems of trauma care. A study of two counties. Arch Surg 114:455460, 1979 13. West JG: Validation of autopsy method for evaluating trauma care. Arch Surg 117:1033-1035, 1982 14. Mayer T, Walker ML, Johnson DG, et al: Causes of morbidity and mortality in severe pediatric trauma. JAMA 245:719-721, 1981 15. Baker SP, O'Neill B, Haddon W Jr, et al: The injury severityscore: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187196, 1974 16. Baker SP, O'Neill B: The injury Severity score: An update. J Trauma 16:882-885, 1976 17. Hailer JA, Signer RD, Golladay ES, et al: Use of a trauma registry in the management of children with lifethreatening injuries. J Pediatr Surg 11:381-390, 1976
R A U M A is the leading cause of death in the pediatric age group, with major injuries accounting for more than half of the deaths in children 14 years and younger.14 The specialized nature of appropriate management of the multiple-trauma patient has been supported by several studies, T M among them a study by West and Trunkey. 12 In 1974 they reviewed the death certificates of 100 consecutive adults who died after having been in automobile accidents. They excluded all patients dead at the scene and all who died primarily as a result of central nervous system injuries. The purpose of the study was to compare the results of management of severe trauma in two California counties, one of which referred patients to a trauma center, and one which referred patients to the hospital nearest the scene of the injury. A second-stage study, in which detailed hospital records were reviewed, confirmed the initial conclusion that a significant number of deaths could have been avoided with more optimal management. With the initiation of a trauma-center program, there is now strong evidence that their conclusion was valid.~3 Stimulated by these studies in the adult population, we reviewed a series of deaths due to injury in metropolitan St. Louis, Missouri, in chidren under the age of 15 years. Our objective was to provide a data base from which to initiate a review of the quality of care available to the
T
Journal of Pediatric Surgery, Vol. 18, No. 4 (August), 1983
pediatric trauma patient in our area where trauma-center designation and triage have yet to be developed. MATERIAL AND METHODS Using the records of the Medical Examiners' Offices of the city of St. Louis and St. Louis County, we reviewed 118 consecutive trauma deaths (excluding drownings and burns) in children 15 years or younger during a 5-year period from 1977 to 1981. Although this time period reflects the documentation of records by a medical examiner rather than a coroner, the content of these records varied from as little as the death certificate and police records to more detailed hospital and autopsy reports. Patients dead at the scene or on arrival were excluded. The mechanism of injury, age, sex, and race were recorded. Diagnostic procedures, consulted services, details of resuscitation, and the type and timing of operation were noted when possible. Also reviewed were transport times, referrals to secondary hospitals, and the time interval between arrival at the ultimate hospital and death. The survival times were calculated based upon information on the death certificate which recorded time of injury and the time of death. Where information allowed, neurologic injury was graded by the Glasgow Coma Scale with conversion to the Modified Injury Severity Scale (MISS) as previously described. ] Injuries to other body areas were graded according to the MISS. In the 86 (73%) patients to whom we were able to assign a MISS score, we reviewed a subset of 59 patients whose score of 40 or less suggested a greater possibility of survival with optimal care.
RESULTS
The mechanisms of injury were: vehicularpedestrian 41%; vehicular-passenger 30%; gunshot wounds 13%; falls 8%, and other 8%. The latter 8% included beatings, a plane crash, a van-train collision, and crush injuries from falling objects. Most of the deaths (42%) involved the age group 11 to 15 years, followed in
From the Washington University School of Medicine and the St. Louis Children's Hospital, Department of Pediatric Surgery, St. Louis, Mo. Presented before the 31st Annual Meeting of the Surgical Section of the American Academy of Pediatrics, New York, New York, October 23-24, 1982. Address reprint requests to Martin J. Bell, MD, 500 South Kingshighway, St. Louis, MO 63110. 9 1983 by Grune & Stratton, Inc. 0022-3468/83/1804-0033/$01.00/0 505
506
frequency by 2 to 5 years (29%), 6 to 10 years (17%), 7 to 24 months (9%), a n d n e w b o r n to 6 months (3%). Fifty percent involved white males, 24% involved white females, 20% involved black males, a n d 6% involved black females. Forty-two percent of the patients were initially seen in 23 hospitals a n d were s u b s e q u e n t l y referred to 15 different hospitals where they received their definitive care a n d then died. T h e r e m a i n i n g 58% were a d m i t t e d and died without transfer in the initial hospital to which they were transported. In all, 38 hospitals were involved in the care of the 118 patients over a 5-year period. T r a n s p o r t time from the site of i n j u r y to either the initial or definitive hospital were available in only 31% of the patients reviewed. O f these, 38% required less t h a n 20 minutes, and 30% took more t h a n 30 minutes. I n f o r m a t i o n concerning the type and t i m i n g of operation were not available in 65% of the cases. O f the r e m a i n i n g 42 patients, 39 patients u n d e r w e n t operative procedure. Details of the t i m i n g a n d conduct of operation were i n a d e q u a t e for further study. Seven percent of the injured children died within one hour of injury, 29% died within four hours, 40% died within 12 hours, and 52% died within the first 24 hours. T h i r t y - o n e percent of the deaths occurred from 1 to 6 days, and 17% died more t h a n one week post injury. T h e time of arrival at the hospital until the time of death was u n k n o w n in 52% of the cases. Six percent died within 30 m i n u t e s of arrival, and 35% died within four hours of arrival. Forty-seven percent of all 118 patients studied sustained nervous system i n j u r y only. Thirty-six percent combined neurological and other body part injuries, a n d 17% had injuries not associated with the nervous system. A M I S S score could be calculated in 86 of the patients. O f these, 9% had scores of less t h a n 25, a n d 69% had scores less t h a n 40. In those patients with a M I S S of less than 40, neurological i n j u r y alone was present in 23 (39%), neurological i n j u r y was combined with other i n j u r y in 19 (32%), a n d non-neurological injuries accounted for 17 (29%). O f the 20 patients whose injuries did not involve the central nervous system, five (25%) were considered, on the basis of available records, to have been preventable deaths. Four of these patients had a M I S S score of 25 or less.
MCKOY AND BELL
CASE REPORTS Case 1 (MISS 25) A 14-year-oldmale sustained a gunshot wound to the right chest. He arrived at the hospital 15 minutes after injury and was observed. One hour later, he "deteriorated and stabilized" with crystaloid administration. Two and one half hours after injury, he again deteriorated with findings of right pleural fluid requiring a chest tube and intubation. He could not be resuscitated, and expired without operation three hours and 20 minutes after arriving at the hospital. Autopsy revealed laceration of the right atrium, pulmonary artery, and pulmonary vein. Comment. Although this patient was ultimately found to have a grave injury, a higher index of suspicion for injury to the mediastinal structures should have dictated a more aggressive diagnostic effort and management of his initial period of deterioration. His exsanguination 11/2hours later, without thoracotomy, represents failure to appreciate the serious nature of the wound.
Case 2 (MISS 25) A 2-year-old male was referred to a second hospital for further evaluation. In the emergency room he had a respiratory rate of 40, pulse of 130, and a temperature of 101.4. No blood pressure was recorded. He was described as lethargic, and multiple areas of ecchymosis on his anterior abdominal wall were noted. X-rays and spinal fluid were obtained, a peripheral IV was established, and the child was observed in the emergency room. He expired three hours later without operation. An autopsy revealed a torn small-bowelmesentery and massive intraabdominal and retroperitoneal bleeding. Comment. A more appropriate assessment of this child with external evidenceof blunt abdominal trauma and recognition of a hypoperfused state would have allowed earlier diagnosis and intervention. Although lethargy and fever may have suggested meningitis, a negative tap should have focused attention on the abdomen.
Case 3 (MISS 43) A 15-year-oldmale was thrown from a van, seen at a local hospital, and referred. He was noted to have bilateral ribfractures, fractured processes of T 12, L 1-3, and right pleural fluid. He had an IVP which was normal and a negative liver-spleen scan. He was admitted, transfused, held NPO, given intravenous fluidsand analgesics,and observed. He was tachycardic and persistently complained of abdominal pain. He became confused and combative at 19 hours post injury. Greater than 24 hours after injury, a right chest tube was placed, obtaining 1000 cc of blood. A central venous catheter (CVC) was placed, with readings of 0 to 3 cm of water 33 hours after admission. An upper-gastrointestinal series revealed a small-bowel perforation. The patient arrested shortly before being taken to the operating room, and could not be resuscitated. Autopsy revealed a subscapular hematoma of the liver, a 1 cm tear of the proximaljejunum with a mesenteric tear, a retroperitoneal hematoma, and peritonitis.
PREVENTABLE TRAUMATICDEATHS Comment. With evidence of significant trauma to the chest (rib fractures and right pleural fluid), earlier placement of a chest tube and careful serial monitoring of arterial blood gases appear to have been indicated. Multiple transverse process fractures and possible ileus would dictate early decompression by nasogastric tube. Use of analgesics may have confused the physical findings, but persistent tachycardia, a confused, combative state, and complaint of abdominal pain suggested the need for careful review of the state of oxygenation and possible unrecognized abdominal injury.
Case 4 (MISS 16) A 2-year-old male sustained blunt abdominal trauma, was seen at a local hospital, and referred. On admission the patient was noted to have a systolic blood pressure of 66 and pulse rate of 192, and was sent to the x-ray department. Four hours later he had a systolic blood pressure of 78 and a pulse of 200. At five hours, he became bradycardic. After a cutdown for venous access was done, a peritoneal lavage revealed bloody return. He underwent exploratory laparotomy with findings of subscapular hematoma of the liver with right adrenal and perinephric hematoma. He continued to deteriorate after operation, and died eight hours later. Comment. This markedly taehycardic child was observed for over three hours without intravenous access or apparent recognition of marginal hemodynamics while prolonged radiographic studies were performed. Case 5 (MISS 9) An 11-year-old male sustained a gunshot wound to the right lower leg while hunting. He was seen at a local hospital where he was given intravenous crystalloid, and referred. He arrived at the definitive hospital alert and oriented with a blood pressure of 100 and pulse of 180. Hematocrit of 5 and hemoglobin of 1 were noted. He was given an additional 2 liters of D5LR and 25 g of albumin. Taken to the operating room one hour after his arrival, he arrested just prior to the induction of anesthesia, and could not be resuscitated. He received the first transfusion of blood in the operating room concomitant with his arrest. Comment. A delay in transfusion (with unmatched O negative blood) appears to account for this patient's preventable death. DISCUSSION D e v e l o p m e n t o f an efficient, effective s y s t e m o f t r a u m a c a r e involves highly o r g a n i z e d , specially t r a i n e d personnel including t r a n s p o r t a t i o n teams, technologists, nurses, a n d physicians who have r e p e a t e d exposure to severely i n j u r e d patients. T r e u f e l and T r u n k e y s t a t e d t h a t an effective t r a u m a p r o g r a m should see a p p r o x i m a t e l y 400 critically injured patients per year. x2 O f the 118 patients studied, 42% were seen at local hospitals and s u b s e q u e n t l y referred to 15 different hospitals. A total o f 38 different hospi-
507 tals were involved in the c a r e o f 118 p a t i e n t s over a 5-year period; an a v e r a g e o f 0.6 patients per hospital per year. It is p r e s u m e d t h a t a similar n u m b e r of hospitals were involved in the c a r e of n o n - f a t a l injuries. E x p e r t c a r e is not likely to develop in such low f r e q u e n c y situations. Conc e n t r a t i n g the c r i t i c a l l y i n u j u r e d patients in regional centers would allow i m p r o v e d experience by highly t r a i n e d individuals at all levels a n d would allow even b e t t e r utilization of existing resources. A t the u l t i m a t e hospital (ie, t h e hospital in which the p a t i e n t received the m a j o r portion of the c a r e a n d s u b s e q u e n t l y expired) the services most frequently consulted were n e u r o s u r g e r y , followed by g e n e r a l s u r g e r y a n d orthopedics. Diagnostic studies most f r e q u e n t l y used were plain r o e n t g e n o g r a m s a n d C T scans. W h e t h e r or not these consultants and d i a g n o s t i c studies were i m m e d i a t e l y a v a i l a b l e is not known from the records reviewed. R e c o g n i z i n g the need for a simple, s t a n d a r d scale which codes the severity o f injury as well as the a n a t o m i c a l location, we elected to use the Modified I n j u r y S e v e r i t y Scale, as published by M a y e r et a l ) J4 This scale has been well docum e n t e d in l a r g e r series of a d u l t patients as an effective tool to c o m p a r e m u l t i p l e injuries, morbidity, a n d m o r t a l i t y . 8't5:6 It provides a basis of c o m p a r i s o n a m o n g patients with m u l t i p l e injuries g r a d e d by other scales a n d m a n a g e d in a v a r i e t y of institutions. A M I S S code could be assigned to 73% ( 8 6 / 118) of the p a t i e n t s reviewed. A w a r e o f the subjective aspects of t h e scoring system, we d i d not assign a score when d a t a were not a d e q u a t e or the m a g n i t u d e of "the injury was unclear. W e assigned a lower score in instances of controversy. O u r use of the scale, therefore, underestim a t e s the severity of injury in q u e s t i o n a b l e cases. R e c o g n i z i n g our l i m i t a t i o n of source by using only the m e d i c a l e x a m i n e r s ' records, we were d i s t u r b e d by the l a c k of objective d a t a a v a i l a b l e even when relatively c o m p l e t e hospital records were included. M u c h i n f o r m a t i o n necessary for periodic review of t h e d e t a i l e d m a n a g e m e n t of a c u t e l y injured patients was absent. I n f o r m a t i o n p e r t a i n i n g to t r a n s p o r t a t i o n a n d resuscitation, a n d to the t i m i n g a n d c o n d u c t of the o p e r a t i o n
508
MCKOY AND BELL
were u n a v a i l a b l e in 69%, 58%, a n d 65% respectively. T h e use of a t r a u m a registry would provide a data base allowing objective, ongoing assessment of t r a u m a m a n a g e m e n t . 17 This is vital i n f o r m a t i o n for a n y productive evaluation of patient care a n d distribution. Five patients of 118 were deemed preventable deaths. Significantly, none of the five had a n y central nervous system injury. In all five patients, there was considerable delay after arrival at the hospital in the recognition of the extent of i n j u r y a n d in the institution of appropriate therapy. This delay occurred in c o m m u n i t y hospitals as well as in university hospital systems which theoretically had the capability of supporting m a j o r t r a u m a t i c injuries. O u r i d e n t i f i c a t i o n of p r e v e n t a b l e d e a t h s emphasizes the need for active participation of pediatric surgeons in the development of orga-
nized t r a u m a care for the pediatric patient. This includes efficient transport teams (capable of resuscitation and support) with centralization of care to reduce the n u m b e r of hospitals involved and allow a broader experience by those capable of providing full support to critically injured patients. This would necessitate the systematic, detailed recording of d a t a in a t r a u m a registry, facilitating periodic critical review of p a t i e n t distribution and m a n a g e m e n t . This also includes education of the public a n d f u n d i n g for more efficient, effective m a n a g e m e n t of the injured pediatric patient. ACKNOWLEDGMENT
We wish to acknowledge the generous cooperation of Dr George E. Gantner, Chief Medical Examiner, and Dr Mary E. Case, Deputy Chief Medical Examiner, of St. Louis City and County.
REFERENCES
1. Mayer T, Matlak ME, Johnson DG, et al: The modified injury severity scale in pediatric multiple trauma patients. J Pediatr Surg 15:719-726, 1980 2. Izant RJ Jr, Hnbay CA: The annual injury of 15,000,000 children: A limited study of childhood accident injury and death. J Trauma 6:65-74, 1966 3. Gratz RR: Accidental injury in childhood: A literature review on pediatric trauma. J Trauma 19:551-555, 1979 4. Trunkey DD: Society of University Surgeons. Presidential address: On the nature of things that go bang in the night. Surgery 92:123-132, 1982 5. Boyd DR: A symposium on the Illinois Trauma Program: A systems approach to the care of the critically injured. J Trauma 13:275-284, 1973 6. Frey CF, Huelke DF, Gikas PW: Resuscitation and survival in motor vehicle accidents. J Trauma 9:292-310, 1960 7. Detmer DE, Moylan JA, Rose J, et al: Regional categorization and quality of care in major trauma. J Trauma 17:592-599, 1977 8. Moylan JA, Detmer DE, RoseJ, et al: Evaluation of the quality of hospital care for major trauma. J Trauma 16:517523, 1976 9. Gertner HR Jr, Baker SP, Rutherford RB, et al:
Evaluation of the management of vehicular fatalities secondary to abdominal injury. J Trauma 12:425--431, 1972 10. Waters JM Jr, Wells CH: The effects of a modern emergencymedical care system in reducing automobile crash deaths. J Trauma 13:645-647, 1973 11. Gill W, Champion HR, Long WB, et al: A clinical experience of major multiple trauma in Maryland. Md State Med J 25:55-58, 1976 12. West JG, Trunkey DD, Lim RC: Systems of trauma care. A study of two counties. Arch Surg 114:455460, 1979 13. West JG: Validation of autopsy method for evaluating trauma care. Arch Surg 117:1033-1035, 1982 14. Mayer T, Walker ML, Johnson DG, et al: Causes of morbidity and mortality in severe pediatric trauma. JAMA 245:719-721, 1981 15. Baker SP, O'Neill B, Haddon W Jr, et al: The injury severityscore: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 14:187196, 1974 16. Baker SP, O'Neill B: The injury Severity score: An update. J Trauma 16:882-885, 1976 17. Hailer JA, Signer RD, Golladay ES, et al: Use of a trauma registry in the management of children with lifethreatening injuries. J Pediatr Surg 11:381-390, 1976