Pediatric Trauma Society

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Direct to Operating Room Pediatric Trauma Resuscitation: a Selective Policy that Decreases Mortality amongst Severely Injured Children
Minna Wieck, Aaron Cunningham, Brandon Behrens, Erika T Ohm, *Mubeen Jafri
Oregon Health Science University, Portland, OR

Background (issue): Providing expedient care for severely injured patients can limit morbidity and increase survival. Direct to operating room (DOR) resuscitation for selective adult patients has demonstrated decreased mortality. We sought to investigate the application of this protocol in children.
Methods: All DOR pediatric patients from 2009-2016 at a Level I Trauma Center were identified. DOR criteria included penetrating injury, chest injuries, amputations, significant blood loss, cardiopulmonary resuscitation, and surgeon discretion. Demographics, injury patterns, interventions, and outcomes were analyzed. Observed mortality was compared to expected using the Trauma Injury Severity Score (TRISS) methodology.
Findings: 82 patients (1 month to 17 years) of 2,956 total trauma activations were resuscitated using DOR policy. The most common indications for DOR were penetrating injuries (61%) and chest injuries (32%). 44% had ISS>15, 33% had GCS<8, and 9% were hypotensive. The most commonly injured body regions were external(66%), head(34%), chest(29%), and abdomen(27%). 78% required emergent procedural intervention(see Table). Predictors of intervention were ISS>15(odds ratio=14) and GCS<9(odds ratio=8.5). The survival rate to discharge for DOR patients was 84.5% compared with expected survival of 79.1 %(TRISS) with most significant improvement in penetrating trauma (84.5%vs.78.5, p=0.002).
Conclusions (implications for practice): A selective policy of resuscitating the most severely injured children in the operating room can decrease mortality. Patients suffering penetrating trauma with the highest ISS and diminished GCS have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies.

Emergent procedural interventions
Interventionn (%)
Laparotomy14 (17%)
Thoracotomy6 (7%)
Craniotomy7 (9%)
Neck exploration6 (7%)
Wound exploration / repair27 (33%)
Vascular repair8 (10%)
Tube thoracostomy15 (18%)
Central venous access16 (20%)
Intracranial pressure monitor4 (5%)

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