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Penetrating Trauma

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By Margot Daugherty, MSN, MEd
Cincinnati Children's Hospital

Miyata S, Cho J, Lebedeveskiy O, Matsushima K, Bae E, Bliss D. Trauma Experts versus Pediatric Experts: Comparison of Outcomes in Pediatric Penetrating Injuries. Journal of Surgical Research. Feb 2017;(208):173-179 doi:10.1016/j.jss.2016.09.040

Abstract

Background: While pediatric trauma centers (PTCs) can uniquely care for pediatric patients, adult trauma centers (ATCs) may be more accessible. Evidence is scarce regarding outcomes of pediatric patients with penetrating trauma treated at PTCs versus ATCs.
Materials and Methods: We performed a retrospective study using the National Trauma Data Bank to identify pediatric patients aged ?18 y with penetrating injuries from 2007 to 2012, treated at stand-alone PTCs or ATCs. We excluded patients treated at combined PTC or ATC, transferred between hospitals, with gunshot wounds (GSW) to he had, or dead on arrival. Eligible patients numbered 26,276 (PTC, n=3737; ATC, n=22,539). The primary outcome was in-hospital mortality. The secondary outcome was discharge location as a potential surrogate for functional outcome. Univariate and multivariate analyses assessed trauma center type as an independent risk factor for outcomes.
Results: Patients treated at ATCs were more likely to have Injury Severity Score >15, Glasgow Coma Scale <9, GSW cardiovascular injuries, and emergent operations (P <0.001). Adjusted odds ratios (ORs) for mortality favored PTCs but without statistical significance (OR, 0.592; P = 0.054). In subgroup analyses, children with aged ?12 y, those with GSW injury mechanism, and those who underwent emergent operations at PTCs were more frequently discharged to home versus elsewhere (OR, 0.327, 0.483, and 0.394; P values <0.001, <0.001, and 0.004, respectively).
Conclusions: Children with penetrating injuries demonstrated equivalent survival outcomes whether they were treated at PTCs or ATCs. Younger pediatric patients may have superior functional outcomes when treated at PTCs.

This is the first study to compare functional outcomes in the setting of pediatric penetrating injury between adult and pediatric free-standing trauma centers. The group hypothesized the treatment to be equivocal and was able to prove the hypothesis. Although the group retrospectively looked at data provided by the NTDB they raise the question of allocation of resources in existing trauma triage systems.

Gurria J, Riney L, Fain E, Brown R, Morales D. Gunshot Wound to Chest with Embolization of Pellet into the Left Ventricle: Case Report of an Airsoft Gun Injury. ACS Case Reviews in Surgery. 2017;1(2):7-11

Abstract

Significant injuries can occur from various types of nonpowder guns (NPGs), such as BB and pellet guns. This is a case report of a gunshot wound to the chest with an NPG.
An adolescent male presented to a pediatric emergency department (ED) hemodynamically stable after being shot at close range in the chest with an airsoft gun. Echocardiogram and computed tomography angiogram (CTA) visualized the pellet inside the left ventricle (LV). Unclear of the risk of embolization, the patient underwent cardiac exploration, which revealed no external injury to the heart or mediastinum; intracardiac exploration, however revealed that the bullet was embedded in the LV myocardium. Given the bullet tract and the absence of cardiac trauma symptoms, it was hypothesized that the bullet traveled to the central circulation and left ventricle (LV) through the right superior pulmonary vein. NPG-related penetrating injuries should be taken seriously and should be considered as dangerous as any other gunshot wound.
The legal nature of NPGs may mislead children and their caregivers into considering these devices to be safe. Despite the positive outcome of our patient, serious injuries by NPGs have led to significant morbidity and mortality in the pediatric population.

This case study highlights the opportunities associated with nonpowder gun injuries that present to emergency departments across the nation. Most injuries are to the face and eyes, however any air gun injury to the thorax should be considered life-threatening.

Bores S, Pajerowski W, Carr B, Holena D, Meisel Z, Mechem C, Band R. The Association of Prehospital Intravenous Fluids and Mortality in Patients with Penetrating Trauma. The Journal of Emergency Medicine. 2018. In Press 1-13 doi:10.1016/j.jemermed.2017.12.046

Abstract

Background: The optimal approach to prehospital care of trauma patients is controversial, and thought to require balancing advanced field interventions with rapid transport to definitive care.
Objective: We sought principally to examine any association between the amount of prehospital IV fluid (IVF) administered and mortality.
Methods: We conducted a retrospective cohort analysis of trauma registry data patients who sustained penetrating trauma between January 2008 and February 2011, as identified in the Pennsylvania Trauma Systems Foundation registry with corresponding prehospital records from the Philadelphia Fire Department. Analyses were conducted with logistic regression models and instrumental variable analysis, adjusted for injury severity using scene vital signs before the intervention was delivered.
Results: There were 1966 patients identified. Overall mortality was 22.60%. Approximately two-thirds received fluids and one-third did not. Both cohorts had similar Trauma and Injury Severity Score – predicted mortality. Mortality was similar in those who received IVF (23.43%) and those who did not (21.30%) (p = 0.212). Patients who received IVF had longer mean scene times (10.82 min) than those who did not (9.18 min) (p = <0.0001), although call times were similar in those who received IVF (24.14 min) and those who did not (23.83 min) (p =0.637). Adjusted analysis of 1722 patients demonstrated no benefit or harm associated with prehospital fluid (odds ratio [OR] 0.905, 95% confidence interval [CI] 0.47-1.75). Instrumental variable analysis utilizing variations in use of IVF across different Emergency Medical Services (EMS) units also found no association between the unit’s percentage of patients that were provided fluids and mortality (OR 1.02, 95% CI 0.96-1.08).
Conclusions: We found no significant difference in mortality or EMS call time between patients who did or did not receive prehospital IVF after penetrating trauma.

This paper looked at patient's ?14 who sustained penetrating trauma in an urban setting. When paired there was no difference in mortality between those patients treated with IVF and those who were not. There was however a difference with longer transport times.

Sampson R, Winter A. Poisoned Development: Assessing Childhood Lead Exposure as a Cause of Crime in a Birth Cohort Followed Through Adolescence. Criminology. 2018. In Press 1-33 doi: 10.1111/1745-9125.12171

Abstract

The consequences of lead exposure for later crime are theoretically compelling, but direct evidence from representative, longitudinal samples is sparse. By capitalizing on an original follow-up of more than 200 infants from the birth cohort of the Project on Human Development in Chicago Neighborhoods matched to their blood lead levels from around age 3 years, we provided several tests. Through the use of four waves of longitudinal data that include measures of individual development, family background, and structural inequalities in how lead becomes embodied, we assess the hypothesized link between early childhood lead poisoning and both parent-reported delinquent behavior and official arrest in late adolescence. We also test for mediating developmental process of impulsivity and anxiety or depression. The results from multiple analytic strategies that make different assumptions reveal a plausibly causal effect of childhood lead exposure on adolescent delinquent behavior but no direct link to arrests. The results underscore lead exposure as a trigger for poisoned development in the early life course and call for greater integration of the environment into theories of individual differences in criminal behavior.

Given the environment of increased gun violence, possible solutions will be difficult through regulation. Getting at the root of the behaviors from a sociological perspective and the environments children are raised in warrants further investigation.

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