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18173

Non-Accidental Trauma: Contemporary Trends In Injury Patterns, Management, and Outcome

Saturday, October 20, 2012: 1:44 PM
Napoleon Ballroom (Hilton Riverside)
Ioanna G. Mazotas, Nicholas A. Hamilton, MD and Martin S. Keller, MD, Pediatric Surgery, Washington University School of Medicine, Saint Louis, MO

Purpose: Non-accidental trauma (NAT) remains a significant cause of morbidity and mortality in the pediatric population. We sought to better define the injury patterns, management, and outcome for these patients.

Methods: Following IRB approval (#201102491), all children managed for NAT at a state-designated level I pediatric trauma center from 1/2003-12/2010 were reviewed. Demographics, injuries, mechanism, perpetrator, management, and outcome were recorded. Data were compared between each half of the study period using Student's t-test and Chi-square (p<0.05 significant).

Results: Over the 8-year period, 325 children (3.0% of trauma registry) carried a diagnosis of injuries related to NAT. Patient demographics included a mean age of 22.52.1 months (range 10 days – 17 years), M:F ratio of 1.6:1, 51.1% Caucasian, 45.5% African American, and mean injury severity score of 12.10.7. Injury mechanisms were blunt force (44.3%), rotational forces (shaking, 20.6%), burn (11.7%), and unknown (23.4%). All children were evaluated with injury-specific imaging modalities along with skeletal survey (84.0%) and head CT (74.2%) as indicated. Screening skeletal surveys identified additional fractures that were not suspected clinically in 23.8% of children. Of the 273 children with skeletal surveys, 147 (53.8%) had follow-up surveys identifying an additional 20 occult fractures. Initial laboratory evaluation consisted of complete blood count (75.7%), comprehensive metabolic panel (72.0%), and coagulation panel (56.6%). The most frequent injuries are shown in the table. Only thermal injuries were more common in children greater than 2 years of age (p<0.05). The majority of patients (81.8%) required no operative intervention. The most common operations performed were burn excision and grafting (19, 38.7% of children with burns), intracranial pressure monitor placement (18, 17.0% of children with TBI), and subdural hematoma evacuation (12, 12.0% of subdural hematomas required evacuation). Overall length of stay was 5.50.4 days (range 1-55), and 33.5% of patients required intensive care unit management. Patients were discharged to home (33.2%), foster care (55.4%), or died in-hospital (10.8%). Over the study period, the total number of children managed for NAT, males, and those under 2 years increased (p<0.05). No changes were noted in injury severity, imaging, laboratory evaluation, length of stay, or mortality.

Conclusion: Non-accidental trauma remains a significant cause of injury in children. The incidence appears to be increasing, particularly among males and younger children. Multiple and occult injuries are common mandating a high index of suspicion and a multidisciplinary approach. These data also support the continued liberal use of screening modalities for the evaluation of these patients.

Table 1: Injuries sustained from NAT

Injury

Number of Patients

Percent of Patients

Subdural hematoma

100

30.8

Skull fracture

78

24.0

Retinal hemorrhage

69

21.2

Upper extremity fracture

36

11.1

Lower extremity fracture

59

18.2

Rib fracture

57

17.4

Intra-abdominal injury

17

5.2

Multiple injuries

116

35.7