Purpose: Trauma is the leading cause of death after the first year of life in pediatrics, but the tools for outcome prediction are complicated and non-specific. We hypothesized that by using 3 simple markers: Cardiac Arrest, Head injury and Coagulopathy, we can improve prediction of mortality for pediatric blunt trauma.
Methods: Retrospective chart review of all severe pediatric blunt trauma patients, seen over a 10 year period in the level 1 trauma center of a free standing Childrens Hospital. We evaluated all these patients for 1) Cardiac Arrest prior to PICU admission (A=arrest, a=no arrest), 2) Head injury, defined as skull fracture, intracranial bleed, or evidence of elevated ICP or cerebral edema on head CT (H=Head Injury, h=no head injury), and 3) Coagulopathy, defined as an INR of >=1.2 (C=coagulopathy, c=no coagulopathy). Patients were identified from the National Pediatric Trauma Registry and then individual charts were reviewed.
Results: 952 patients were included, of which 61 had a cardiac arrest, 505 patients had a head injury, and 386 had neither. Mean age was 8.6±5.1 years, and 61% of patients were male. Mechanism of injury was predominantly motor vehicle collisions (76%), but also included Non-Accidental Trauma (3.5%), falls and low speed collisions (20%). Of patients with head injury, 67% had a skull fracture, 72% had evidence of intracranial bleed, and 7.5% showed evidence of cerebral edema or increased ICP. Almost half (46%) of the patients had an INR >=1.2.
Mortality of patients with traumatic cardiac arrest (group A) is 93.4% (57/61). In patients without cardiac arrest and without head injury, mortality is 0% in both those with (ahC) and without (ahc) coagulopathy, 0/150 and 0/236 respectively. For patients with a head injury and without cardiac arrest, those without coagulopathy (aHc) had lower mortality than those with coagulopathy (aHC). [1% (2/193) vs 25.2% (61/242), p <0.0001]
Mortality increases as INR increases. Although the elevation of INR is associated with a higher Injury Severity Score, the risk of mortality is also increased within groups of similar severity.
Conclusion: Mortality from pediatric trauma is strongly associated with cardiac arrest. For patients who have not suffered cardiac arrest, head injury with coagulopathy is strongly associated with mortality even at levels of INR that are only mildly increased. Stratifying patients based on AHC is a simple tool for predicting mortality of pediatric blunt trauma patients and requires only history, head CT, and coagulation studies.
The AHC tool should next be used as a prospective predictor, then as support to evaluate outcomes after correction of coagulopathy in Head Injury.