Direct to operating room trauma resuscitation decreases mortality among severely injured children

Minna M. Wieck, Aaron J. Cunningham, Brandon Behrens, Erika T. Ohm, Bryan G. Maxwell, Nicholas Hamilton, M. Christopher Adams, Frederick J. Cole, Mubeen Jafri

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

BACKGROUND Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, 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 to 2016 at a pediatric Level I trauma center were identified. Direct to OR 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 with expected mortality, calculated using Trauma Injury Severity Score methodology, with two-tailed t tests, and a p value less than 0.5 was considered significant. RESULTS Of 2,956 total pediatric trauma activations, 82 (2.8%) patients (age range, 1 month to 17 years) received DOR resuscitation during the study period. The most common indications for DOR were penetrating injuries (62%) and chest injuries (32%). Forty-four percent had Injury Severity Score (ISS) greater than 15, 33% had Glasgow Coma Scale (GCS) score of 8 or less, and 9% were hypotensive. The most commonly injured body regions were external (66%), head (34%), chest (30%), and abdomen (27%). Sixty-seven (82%) patients required emergent procedural intervention, most commonly wound exploration/repair (35%), central venous access (22%), tube thoracostomy (19%), and laparotomy (18%). Predictors of intervention were ISS greater than 15 (odds ratio, 14; p = 0.013) and GCS < 9 (odds ratio = 8.5, p = 0.044). The survival rate to discharge for DOR patients was 84% compared with an expected survival of 79% (Trauma Injury Severity Score) (p = 0.4). The greatest improvement relative to expected mortality was seen in the subgroup with penetrating trauma (84.5% vs 74.4%; p = 0.002). CONCLUSION A selective policy of resuscitating the most severely injured children in the OR can decrease mortality. Patients suffering penetrating trauma with the highest ISS, and diminished GCS scores have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies.

Original languageEnglish (US)
Pages (from-to)659-664
Number of pages6
JournalJournal of Trauma and Acute Care Surgery
Volume85
Issue number4
DOIs
StatePublished - Oct 1 2018

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Operating Rooms
Resuscitation
Injury Severity Score
Mortality
Wounds and Injuries
Glasgow Coma Scale
Thoracic Injuries
Trauma Centers
Pediatrics
Odds Ratio
Thoracostomy
Body Regions
Cardiopulmonary Resuscitation
Amputation
Abdomen
Laparotomy
Thorax
Survival Rate
Head
Demography

Keywords

  • direct to OR
  • mortality
  • pediatric
  • resuscitation
  • Trauma

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

Direct to operating room trauma resuscitation decreases mortality among severely injured children. / Wieck, Minna M.; Cunningham, Aaron J.; Behrens, Brandon; Ohm, Erika T.; Maxwell, Bryan G.; Hamilton, Nicholas; Adams, M. Christopher; Cole, Frederick J.; Jafri, Mubeen.

In: Journal of Trauma and Acute Care Surgery, Vol. 85, No. 4, 01.10.2018, p. 659-664.

Research output: Contribution to journalArticle

Wieck, Minna M. ; Cunningham, Aaron J. ; Behrens, Brandon ; Ohm, Erika T. ; Maxwell, Bryan G. ; Hamilton, Nicholas ; Adams, M. Christopher ; Cole, Frederick J. ; Jafri, Mubeen. / Direct to operating room trauma resuscitation decreases mortality among severely injured children. In: Journal of Trauma and Acute Care Surgery. 2018 ; Vol. 85, No. 4. pp. 659-664.
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abstract = "BACKGROUND Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, 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 to 2016 at a pediatric Level I trauma center were identified. Direct to OR 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 with expected mortality, calculated using Trauma Injury Severity Score methodology, with two-tailed t tests, and a p value less than 0.5 was considered significant. RESULTS Of 2,956 total pediatric trauma activations, 82 (2.8{\%}) patients (age range, 1 month to 17 years) received DOR resuscitation during the study period. The most common indications for DOR were penetrating injuries (62{\%}) and chest injuries (32{\%}). Forty-four percent had Injury Severity Score (ISS) greater than 15, 33{\%} had Glasgow Coma Scale (GCS) score of 8 or less, and 9{\%} were hypotensive. The most commonly injured body regions were external (66{\%}), head (34{\%}), chest (30{\%}), and abdomen (27{\%}). Sixty-seven (82{\%}) patients required emergent procedural intervention, most commonly wound exploration/repair (35{\%}), central venous access (22{\%}), tube thoracostomy (19{\%}), and laparotomy (18{\%}). Predictors of intervention were ISS greater than 15 (odds ratio, 14; p = 0.013) and GCS < 9 (odds ratio = 8.5, p = 0.044). The survival rate to discharge for DOR patients was 84{\%} compared with an expected survival of 79{\%} (Trauma Injury Severity Score) (p = 0.4). The greatest improvement relative to expected mortality was seen in the subgroup with penetrating trauma (84.5{\%} vs 74.4{\%}; p = 0.002). CONCLUSION A selective policy of resuscitating the most severely injured children in the OR can decrease mortality. Patients suffering penetrating trauma with the highest ISS, and diminished GCS scores have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies.",
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AU - Wieck, Minna M.

AU - Cunningham, Aaron J.

AU - Behrens, Brandon

AU - Ohm, Erika T.

AU - Maxwell, Bryan G.

AU - Hamilton, Nicholas

AU - Adams, M. Christopher

AU - Cole, Frederick J.

AU - Jafri, Mubeen

PY - 2018/10/1

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N2 - BACKGROUND Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, 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 to 2016 at a pediatric Level I trauma center were identified. Direct to OR 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 with expected mortality, calculated using Trauma Injury Severity Score methodology, with two-tailed t tests, and a p value less than 0.5 was considered significant. RESULTS Of 2,956 total pediatric trauma activations, 82 (2.8%) patients (age range, 1 month to 17 years) received DOR resuscitation during the study period. The most common indications for DOR were penetrating injuries (62%) and chest injuries (32%). Forty-four percent had Injury Severity Score (ISS) greater than 15, 33% had Glasgow Coma Scale (GCS) score of 8 or less, and 9% were hypotensive. The most commonly injured body regions were external (66%), head (34%), chest (30%), and abdomen (27%). Sixty-seven (82%) patients required emergent procedural intervention, most commonly wound exploration/repair (35%), central venous access (22%), tube thoracostomy (19%), and laparotomy (18%). Predictors of intervention were ISS greater than 15 (odds ratio, 14; p = 0.013) and GCS < 9 (odds ratio = 8.5, p = 0.044). The survival rate to discharge for DOR patients was 84% compared with an expected survival of 79% (Trauma Injury Severity Score) (p = 0.4). The greatest improvement relative to expected mortality was seen in the subgroup with penetrating trauma (84.5% vs 74.4%; p = 0.002). CONCLUSION A selective policy of resuscitating the most severely injured children in the OR can decrease mortality. Patients suffering penetrating trauma with the highest ISS, and diminished GCS scores have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies.

AB - BACKGROUND Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, 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 to 2016 at a pediatric Level I trauma center were identified. Direct to OR 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 with expected mortality, calculated using Trauma Injury Severity Score methodology, with two-tailed t tests, and a p value less than 0.5 was considered significant. RESULTS Of 2,956 total pediatric trauma activations, 82 (2.8%) patients (age range, 1 month to 17 years) received DOR resuscitation during the study period. The most common indications for DOR were penetrating injuries (62%) and chest injuries (32%). Forty-four percent had Injury Severity Score (ISS) greater than 15, 33% had Glasgow Coma Scale (GCS) score of 8 or less, and 9% were hypotensive. The most commonly injured body regions were external (66%), head (34%), chest (30%), and abdomen (27%). Sixty-seven (82%) patients required emergent procedural intervention, most commonly wound exploration/repair (35%), central venous access (22%), tube thoracostomy (19%), and laparotomy (18%). Predictors of intervention were ISS greater than 15 (odds ratio, 14; p = 0.013) and GCS < 9 (odds ratio = 8.5, p = 0.044). The survival rate to discharge for DOR patients was 84% compared with an expected survival of 79% (Trauma Injury Severity Score) (p = 0.4). The greatest improvement relative to expected mortality was seen in the subgroup with penetrating trauma (84.5% vs 74.4%; p = 0.002). CONCLUSION A selective policy of resuscitating the most severely injured children in the OR can decrease mortality. Patients suffering penetrating trauma with the highest ISS, and diminished GCS scores have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies.

KW - direct to OR

KW - mortality

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