Outcome of Cardiovascular Collapse in Pediatric Blunt Trauma,☆☆,

An abstract of this paper was presented at the National Conference on Pediatric Trauma in Indianapolis, Indiana, September 1992.
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Abstract

Study objectives: To determine the survival and functional outcome of pediatric blunt trauma victims demonstrating cardiovascular collapse, including pulseless cardiopulmonary arrest or severe hypotension, on initial presentation in an emergency department. Design: Seven-year consecutive case-control series. Setting: Level I trauma center and university teaching hospital. Participants: Two thousand one hundred twenty consecutive pediatric victims of blunt trauma less than 16 years old admitted to a Level I trauma center from August 1984 through December 1991 had a mortality of 5.2%. Thirty-eight patients (1.8%) demonstrated pulseless cardiac arrest or severe hypotension (systolic blood pressure of 50 mm Hg or less) on initial presentation in the ED. Interventions: All patients received basic and advanced life support consistent with guidelines published by the American Heart Association, American Academy of Pediatrics, and American College of Surgeons. Measurements and main results: Survival, functional outcome, and donor status were reviewed. Outcome of ED resuscitation (death or reanimation), post-ED destination (morgue, operating room, or pediatric ICU) length of hospitalization, functional outcome after hospital discharge, time to death (time from admission to ED to declaration of death), cause of death, total hospital costs, total hospital charges, and organ donation were reviewed. There were no functional survivors among 38 pediatric victims of blunt trauma who presented to the ED in pulseless cardiac arrest or with severe hypotension. Eleven of the 12 patients who were transferred to the pediatric ICU died; the single survivor demonstrated profound neurologic impairment six years after hospitalization. Six of these 12 patients were eligible potential donors and resulted in four multiorgan donors during the seven-year study. The mean hospital unreimbursed care for the 38 study patients was $3,514 per patient. Conclusion: No child who presented with pulseless cardiac arrest or severe hypotension following blunt trauma achieved functional survival. Reimbursed care for pediatric victims of blunt trauma demonstrating cardiovascular collapse is disproportionately poor compared with that for pediatric patients who maintain hemodynamic integrity in the ED. Half of all patients who were stabilized sufficiently for transfer to the pediatric ICU were eligible potential organ donors. Therefore aggressive resuscitation of these patients may be justified if organ donation is seriously contemplated and aggressively pursued.

[Hazinski MF, Chahine AA, Holcomb GW III, Morris JA Jr: Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med June 1994;23:1229-1235.]

Section snippets

INTRODUCTION

Trauma is a leading cause of pediatric death and disability in the United States. Each year, more than 22,000 children die and many more are hospitalized as the result of injuries, resulting in annual health care expenditures exceeding $7.5 billion.1, 2 Blunt trauma is responsible for 90% of pediatric trauma and most pediatric trauma deaths and disability.2 Approximately 80% of all pediatric trauma deaths occur within the first hours of injury; it is estimated that half occur at the scene, and

MATERIALS AND METHODS

During the study period of August 1984 through December 1991, 12,420 patients of all ages were admitted to a university Level I trauma center with traumatic injuries. Twenty percent of these trauma patients (2,511 patients) were less than 16 years old. Blunt trauma was the mechanism of injury in 2,120 (84.4%) of these children. The records of all 2,120 patients were screened for evidence of cardiopulmonary arrest or severe hypotension on initial presentation in the medical center ED, and

RESULTS

During the study period, 2,120 consecutive victims of blunt trauma less than 16 years old were evaluated; 2,082 of these patients presented with a systolic blood pressure of more than 50 mm Hg on admission to the ED and formed the nonstudy group. The mean ISS of the 2,082 nonstudy patients was 10.1, and the mean TRISS was 95.2%, with an actual survival of 96.5%. The mean age of these patients was 7.1 years (range, 3 months to 15 years) and the mean length of stay was 6.0 days (Table 1). The

DISCUSSION

Cardiac arrest is a dismal prognostic sign in adult victims of blunt trauma, and resuscitation rarely results in functional survival.4, 5, 6, 7, 8, 9, 10, 11, 12 Reports of small groups of patients have suggested that the survival following cardiac arrest in pediatric trauma victims is as poor as that reported following arrest in adult victims,19, 26 although no large series has been published to confirm this fact. There are, however, important distinctions between the epidemiology of pediatric

CONCLUSION

The outcome of pulseless cardiac arrest or profound hypotension (characterized by a systolic blood pressure of 50 mm Hg or less) among pediatric victims of blunt trauma is dismal. The length of hospitalization and the cost of care is relatively low in these patients; however, reimbursement for their care is still disproportionately poor. Although functional survival is unlikely, if pediatric victims of blunt trauma presenting with pulseless arrest or profound hypotension can be stabilized

References (30)

  • Division for Injury Control, Center for Environmental Health and Injury Control, Centers for Disease Control

    Childhood injuries in the United States

    Am J Dis Child

    (1990)
  • S Shimazu et al.

    Outcomes of trauma patients with no vital signs on hospital admission

    J Trauma

    (1983)
  • EE Moore et al.

    Post-injury thoracotomy in the emergency department: A critical evaluation

    Surgery

    (1979)
  • CC Baker et al.

    The role of emergency room thoracotomy in trauma

    J Trauma

    (1980)
  • PD Danne et al.

    Emergency bay thoracotomy

    J Trauma

    (1984)
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    From Vanderbilt University Medical Center, Nashville, Tennessee.

    ☆☆

    Address for reprints: Mary Fran Hazinski, RN, MSN, FAAN, Division of Trauma, 2100 Pierce Avenue, 243 MCS, Vanderbilt University Medical Center, Nashville, Tennessee 37212, 615-936-0175, Fax 615-936-0185

    Reprint no. 47/1/55752

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