Trauma remains the most common cause of death and morbidity

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1 ORIGINAL ARTICLE Survival of pediatric blunt trauma patients presenting with no signs of life in the field Vincent Duron, MD, Rita V. Burke, PhD, MPH, David Bliss, MD, Henri R. Ford, MD, MHA, and Jeffrey S. Upperman, MD, Los Angeles, California BACKGROUND: Prehospital traumatic cardiopulmonary arrest is associated with dismal prognosis, and patients rarely survive to hospital discharge. Recently established guidelines do not apply to the pediatric population because of paucity of data. The study objective was to determine the survival of pediatric patients presenting in the field with no signs of life after blunt trauma. METHODS: We conducted a retrospective analysis of the National Trauma Data Bank research data set (2002Y2010). All patients 18 years and younger with blunt traumatic injuries were identified (DRG International Classification of DiseasesV9th Rev. codes 800Y869). No signs of life (SOL) was defined on physical examination findings and included the following: pulse, 0; respiratory rate, 0; systolic blood pressure, 0; and no evidence of neurologic activity. These same criteria were reassessed on arrival at the emergency department (ED). Furthermore, we examined patients presenting to the ED who underwent resuscitative thoracotomy (Current Procedural Terminology code 34.02). Our primary outcome was survival to discharge from the hospital. RESULTS: There were a total of 3,115,597 pediatric patients who were found in the field after experiencing blunt trauma. Of those, 7,766 (0.25%) had no SOL. Seventy percent of the patients with no SOL in the field were male. Survival to hospital discharge of all patients presenting with no SOL was 4.4% (n = 340). Twenty-five percent of the patients in the field with no SOL were successfully resuscitated in the field and regained SOL by the time they arrived to the ED (n = 1,913). Of those patients who regained SOL, 13.8% (n = 265) survived to hospital discharge. For patients in the field with no SOL, survival to discharge was significantly higher in patients who did not receive a resuscitative thoracotomy than in those who did. CONCLUSION: Survival of pediatric blunt trauma patients in the field without SOL is dismal. Resuscitative thoracotomy poses a heightened risk of blood-borne pathogen exposure to involved health care workers and is associated with a significantly lower survival rate. (. 2014;77: 422Y426. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Prognostic study, level III; therapeutic study, level IV. KEY WORDS: Emergency; pediatric; survival; thoracotomy; trauma. Trauma remains the most common cause of death and morbidity in children older than 1 year in the United States. 1,2 With the regionalization and standardization of trauma care, well-developed transport and communication systems, and improved prehospital care, trauma patients who would have in the past died of their injuries in the field are now being resuscitated and transported to trauma centers. 3,4 Despite these advancements, multiple studies have demonstrated that prehospital traumatic cardiopulmonary arrest (TCPA) continues to be associated with a dismal prognosis and that these patients rarely survive to hospital discharge. 5,6 Recently, the National Association of Emergency Medical Service Physicians (NAEMSP) and the American College of Surgeons Committee on Trauma set forth guidelines indicating that resuscitation efforts may be withheld in any blunt trauma patient Submitted: September 13, 2013, Revised: April 14, 2014, Accepted: April 16, From the Department of Pediatric Surgery (V.D., R.V.B., D.B., H.R.F., J.S.U.), Children s Hospital Los Angeles; and Keck School of Medicine (R.V.B., D.B., H.R.F., J.S.U.), University of Southern California, Los Angeles, California. This study was presented as a poster at 72nd annual meeting of the American Association for the Surgery of Trauma, September 18Y21, 2013, in San Francisco, California. Address for reprints: Jeffrey S. Upperman, MD, Department of Pediatric Surgery, Children s Hospital Los Angeles, Keck School of Medicine, University of Southern California, 4650 Sunset Blvd, Mailstop #100, Los Angeles, CA 90027; jupperman@chla.usc.edu. DOI: /TA who, based on out-of-hospital personnel s thorough primary patient assessment, is found apneic, pulseless, and without organized ECG activity upon arrival of EMS at the scene. The NAEMSP clearly states, however, that these guidelines do not apply to the pediatric population, mostly because of the paucity of data on pediatric patients presenting with these findings. 7 Although there are few studies examining pediatric patients who undergo prehospital TCPA, survival rates in these series are just as dismal as in adult studies, ranging from 0% to 4%. 8Y11 The decision to withhold or terminate resuscitation in the field, however, is a difficult one, particularly in children. Anecdotal reports of successful resuscitation including emergency department (ED) thoracotomy have fostered the hope that pediatric patients may tolerate the physiologic stress of severe trauma better than their adult counterparts. 12 Nevertheless, the outcomes of ED thoracotomy for blunt trauma in children are still dismal, with survival rates ranging from 0% to 4.8%. 13Y16 All studies examining this issue are small retrospective studies involving less than 50 patients. The objectives of our study were to analyze data from the National Trauma Data Bank (NTDB) and to determine the survival rate of pediatric patients presenting in the field with no vital signs after blunt trauma. Further analysis will determine the impact on outcome that resuscitation in the field, resuscitation in the ED, and ED thoracotomy have on survival. We postulate that survival in these patients will be exceedingly low and that resuscitative measures, including ED thoracotomy, will not improve survival.

2 Duron et al. PATIENTS AND METHODS Study Design and Population After institutional board review approval, we conducted a retrospective review of the American College of Surgeons NTDB research data set (2002Y2010). All patients 18 years and younger who experienced blunt traumatic injuries were identified (DRG International Classification of DiseasesV9th Rev. codes 800Y869). For each patient, we identified age, sex, race, mechanism of injury, and Injury Severity Score (ISS). No signs of life was defined on physical examination findings as recorded and included the following: no pulse (pulse, 0), no respiratory rate (respiratory rate, 0), no obtainable blood pressure (systolic blood pressure, 0) and no evidence of neurologic activity (Glasgow Coma Scale [GCS] score, 3: eyes, 1; verbal, 1; motor, 1). All four findings were required to be characterized as having no signs of life. These same four criteria were then reassessed on arrival to the ED. At this point, subjects were separated into responders (presence of at least one sign of life: pulse 9 0or respiratory rate 9 0 or systolic blood pressure 9 0orGCS score 9 3) and nonresponders (persistence of no signs of life) of field resuscitation. Furthermore, we examined which patients presenting to the ED underwent exploratory thoracotomy within 24 hours of arriving to the ED (Current Procedural Terminology code 34.02). Outcome Variables Our primary outcome of interest was survival to discharge from the hospital. We compared survival between children who responded to field resuscitation and presented to the ED with signs of life and those who did not. Then, we compared survival among patients who underwent exploratory thoracotomy and those who did not. Statistical Analysis The frequency distribution of demographic and injuryrelated variables including age, sex, ethnicity, and mechanism of injury, were examined. Odds ratios (ORs) and 95% confidence intervals (CIs) of death were estimated by unconditional multiple logistic regression with and without adjustment for potential confounders. Mechanism of injury (categorical) was included as dummy variables in the model. W 2 test was used to compare categorical data. All statistical analyses were performed using SAS version 9.2 (Cary, NC), and all p values were two sided. RESULTS Among patients 18 years and younger, there were a total of 3,115,597 patients who were treated by EMS for blunt trauma (including head, neck, chest, abdominal, and/or extremity blunt trauma). Of those patients, 7,766 (0.25%) had no signs of life when they were found in the field. Seventy percent of the patients found with no signs of life in the field were male. Population demographics included 12.7% younger than 1 year, 22% 1 year to 4 years old, 10.5% 5 years to 9 years old, 14.1% 9 years to 14 years old, and 40.7% 15 years to 18 years old. Eighty-four percent of these children had major trauma (ISS 9 15), and 81.8% of them had an ISS greater than 25. Thirty-eight percent were white, 35% were black, 1.4% were Asian, and 0.4% were American Indian. Sex, age, and race were not predictive of survival. However, ISS and mechanism of trauma did correlate with survival in these patients (Table 1). Survival to hospital discharge of all patients presenting with no signs of life was 4.4% (n = 340). Twenty-five percent of the patients found with no signs of life were successfully resuscitated by EMS in the field and had regained signs of life by the time they arrived to the ED (n = 1,913). Of those patients who had regained signs of life, 13.8% (n = 265) survived to hospital discharge. Seventy-five percent of the patients, however, still did not have signs of life by the time they arrived at the ED (n = 5,853). Only 1.5% (n = 89) of those patients survived to hospital discharge (Table 2). Of all patients with blunt trauma who were found with no signs of life in the field, 6.4% (n = 499) underwent a resuscitative ED thoracotomy. Of these patients, only 1.3% survived to hospital discharge. On unadjusted analysis, survival was significantly higher in patients who did not receive a resuscitative EDthoracotomythaninthosewhodid,evenwhentheyhad regained signs of life in the ED (Table 2). On multiple logistic regression, only the return of vital signs (or lack thereof) upon arrival to the ED and ISS were associated with the likelihood of survival in patients presenting TABLE 1. Demographic Characteristics of Patients With Blunt Trauma Who Presented With No Vitals in the Field, by Survival* No Vitals in Field Who Survived (n = 340)** No Vitals in Field Who Did Not Survive (n = 7,426) Sex Male 62 (69.7) 853 (71.2) Female 26 (29.2) 337 (28.1) Age, y G1 14 (15.7) 116 (9.7) 1Y4 22 (24.7) 231 (19.3) 5Y9 9 (10.1) 130 (10.8) 9Y14 14 (15.7) 151 (12.6) 15Y18 30 (33.7) 572 (47.7) Race American Indian 1 (1.1) 4 (0.33) Asian 2 (2.3) 16 (1.3) Black 26 (29.2) 427 (35.6) White 39 (43.8) 454 (37.8) Other 18 (20.2) 193 (16.1) NA/not recorded 18 (3.3) 106 (8.8) ISS G Y (34.3) 1,261 (18.0) 16Y (65.8) 5,736 (82.0) Mechanism of trauma Fall 36 (20.0) 420 (11.8) Motor vehicle crash 110 (61.1) 2,163 (60.8) Automobile against 26 (14.4) 855 (24.1) pedestrian Bicycle 8 (4.4) 117 (3.3) *Values may not add up to the total because of missing values. **Patients who survived are patients who were discharged from the hospital alive. p * 2014 Lippincott Williams & Wilkins 423

3 Duron et al. TABLE 2. Comparison of Survival Between Patients Who Received a Thoracotomy and Those Who Did Not (n = 7,766) (n = 7,766) or in ED (n = 5,853) but signs of life in ED (n = 1,913) Thoracotomy No Thoracotomy Discharged, n (%) Died, n (%) Discharged, n (%) Died, n (%) p 7 (1.3) 492 (98.6) 333 (4.6) 6,937 (95.4) (3.5) 398 (99.3) 83 (1.5) 5,369 (99.5) (4.1) 94 (95.9) 250 (13.8) 1,565 (86.2) with no vitals in the field after blunt trauma. Having regained vitals after field resuscitation was associated with a 0.19 adjusted OR of death (p G ). ISS greater than 15 was associated with a 2.6 adjusted OR of death (p = ). Sex, race, age, and mechanism of injury did not correlate with survival. Furthermore, thoracotomy was also not associated with survival in this analysis (Table 3). DISCUSSION Prehospital TCPA from blunt trauma is associated with a dismal prognosis. This has been verified in multiple adult studies. In a retrospective review of 267 patients who experienced TCPA, Shimazu et al. 5 found a 2.3% survival rate among blunt trauma patients. Stratton et al. 6 found only 1.6% survival rate among blunt trauma patients with TCPA and all were neurologically devastated. Rosemurgy et al. 17 found zero survivor among blunt trauma patients who underwent cardiopulmonary resuscitation (CPR) at the scene or during transport. Finally, Battistella et al. 18 examined 604 trauma patients who required prehospital CPR. Of those patients, 304 had sustained blunt trauma. Only 1.3% (4 of 304) survived to hospital discharge. No patient survived to leave the hospital if the initial electrical heart rate was less than 40 beats/min. Furthermore, 57% of those who survived had severe neurologic impairment. Such findings have led to the establishment of guidelines to withhold resuscitation efforts in the field for adult patients presenting with no signs of life. The guidelines set forth by the TABLE 3. Crude and Adjusted ORs and 95% CIs of Selected Variables and Association Between Death Variable Crude OR (95% CI) Adjusted OR* (95% CI) p Having vitals in field and ED No V Yes 0.10 (0.08Y0.13) 0.19 (0.12Y0.32) G Sex Male V Female 1.1 (0.66Y1.7) 0.75 (0.44Y1.3) Race White V Non-white** 1.3 (0.82Y2.0) 1.1 (0.67Y1.8) Age, y G V 1Y4 1.3 (0.63Y2.6) 0.87 (0.40Y1.9) Y9 1.7 (0.73Y4.2) 1.4 (0.55Y3.6) Y (0.60Y2.8) 1.3 (0.53Y3.3) Y (1.2Y4.4) 1.4 (0.66Y3.0) ISS 0Y V 16Y (1.9Y3.0) 2.6 (1.5Y4.4) Thoracotomy within 24 h No V Yes 3.4 (1.6Y7.1) 3.6 (0.48Y27.3) Mechanism Fall V Motor vehicle crash 0.90 (0.71Y1.1) 1.1 (0.57Y2.0) Automobile against pedestrian 1.5 (0.99Y2.3) 1.4 (0.67Y3.1) Bicycle 0.67 (0.32Y1.4) 0.32 (0.09Y1.1) *Adjusted for the other variables in the table. **Includes, Asian, black, Hawaiian, other, unknown/american Indian American. 424 * 2014 Lippincott Williams & Wilkins

4 Duron et al. NAEMSP on when to suspend resuscitation efforts in the field rely purely on physical examination findings, electrocardiogram (ECG) tracings, and clinical assessment of out-of-hospital health care provider. Findings in the pediatric literature point to similarly dismal outcomes in children who present with prehospital TCPA after blunt trauma. Four studies have examined survival rates among pediatric patients who undergo prehospital TCPA. Calkins et al. 8 found only 2 survivors of 25 patients who underwent CPR in the field or in the ED. The two survivors both had vitals in the field and CPR was administered initially in the ED. In a 10-year retrospective study of all pulseless trauma patients younger than 16 years in whom CPR was initiated in a prehospital or inhospital setting, Suominen et al. 11 found only 1 survivor of 27 patients who had an arrest in the field. Fisher et al. 9 found a 94% mortality rate among children who had undergone CPR before arrival or on arrival to the hospital. Of the 65 patients, the only survivor was discharged in a vegetative state after 89 days in the hospital. It is unclear if he had an arrest in the field or in the hospital. In a study by Hazinski et al. 10 of 38 patients who demonstrated pulseless cardiac arrest or severe hypotension on initial presentation in the ED, only 1 survived, and he demonstrated profound neurologic impairment 6 years after hospitalization. Only one study has examined termination of resuscitation guidelines in the pediatric population. Capizzani et al. 19 identified 30 patients who met criteria for termination of care as set forth by the NAEMSP and determined survival based on the presence of these criteria. They included CPR greater than 15 minutes, nonreactive pupils, absent pulse, and disorganized rhythm on ECG. Of the patients who fulfilled all four criteria, there were no survivors. They also found that CPR greater than 15 minutes and fixed pupils significantly distinguished survivors from nonsurvivors. The ED thoracotomy is, perhaps, the ultimate resuscitative intervention for trauma, although survival and neurologic outcomes remain poor for blunt trauma patients. The NAEMSP has gone so far as to say that ED thoracotomy does not appear to have a role in prehospital TCPA as a result of blunt trauma. 7 While survival after ED thoracotomy for penetrating injury in adults is 9% to 10%, after blunt injury, it is only 1% to 2%. 20 Four studies have examined this in children, and the results are similar. Beaver et al. 13 found 0 survivor of 15 blunt trauma patients requiring ED thoracotomy. They concluded that ED thoracotomy did not influence survival in this group of patients. Sheikh et al. 16 also found zero survivor after ED thoracotomy for blunt traumatic injury (0 of 15). They concluded that children who arrive to the ED following blunt trauma with no cardiac rhythm are unsalvageable and should not undergo ED thoracotomy. Hofbauer et al. 14 again found 0 of 10 survivors among pediatric patients undergoing ED thoracotomy for blunt trauma. Finally, Rothenberg et al. 15 found 1 of 47 survivors after blunt trauma and no survivors when vital signs were absent on arrival to the ED. The results from pediatric studies are consistent, yet the numbers are small. We analyzed 7,706 pediatric patients presenting with no signs of life in the field. Our criteria defining no signs of life were all physical examination findingsvpulseless, apneic, with no blood pressure, and no evidence of neurologic activity. These criteria are obtainable by any trained health care provider and do not require ancillary equipment. This study confirms the results of previous smaller studies: pediatric blunt trauma patients found with no signs of life in the field have a dismal prognosisvonly 4.4% survive to hospital discharge. If they continue to have no signs of life when they arrive to the ED, their prognosis is even poorervonly 1.5% survive. If patients regain signs of life, survival is significantly better at 13.8%. Interestingly, in a multiple regression analysis adjusting for confounding variables (age, sex, race, ISS, mechanism), ED thoracotomy did not improve survival. The only parameters that influenced survival were whether patients had regained signs of life by the time they arrivedtotheedandtheiriss. This finding is significant, particularly in children. Although the prognosis is similar to adults, the emotional demands of withholding resuscitation from a child in the field are great. As mentioned previously, anecdotal reports and the belief that children tolerate ischemia and the physiologic stress of severe trauma better than adults make abandoning resuscitation difficult. The present study further supports previous findings that resuscitation in the field improves outcomes. Based on these data, EMS providers should not be discouraged from resuscitating blunt pediatric trauma patients found in the field with no signs of life. However, ED staff, trauma surgery, and pediatric surgery providers should consider withholding heroic resuscitative maneuvers such as ED thoracotomy in children with no signs of life after blunt trauma. Multiple studies have highlighted the risks to medical staff that are incurred during ED thoracotomy. 21,22 The adult patients who sustain injuries requiring ED thoracotomy have been found to have higher rates of human immunodeficiency virus and hepatitis infection, which can be as high as 12%. 23 ED thoracotomy involves the rapid use of sharp instruments with multiple providers working in close quarters, which increases the chance of exposure to patients blood. The increased personnel exposure risk, combined with unacceptably low likelihood of benefit to the patient further militates against the use of ED thoracotomy for blunt pediatric patients presenting with no vitals in the field. Although we were able to obtain a large number of patients through our analysis of the NTDB, with this analysis come several limitations. The analysis is retrospective, and although the large number of patients lessens the effect of bias associated with such analyses, this does not completely disappear. Second, to study the use of ED thoracotomy for our trauma patients, we were limited in defining ED thoracotomy as an exploratory thoracotomy that occurred within the first 24 hours of admission to the ED. It may be possible that a number of these procedures were not performed in the ED or were not performed for resuscitative reasons. We also do not know the indication for the thoracotomy. A number of patient parameters would have been interesting to study but were not available through the NTDB, such as ECG tracing in the field, pupillary activity, and length of CPR. However, the four criteria that we chose to study are easy to replicate, and valid parameters to measure in the field when ancillary equipment may not be available. Finally, we were able to study only survival upon discharge and not long-term survival or neurologic outcome. The latter is particularly important because the high frequency of neurologic devastation in the analogous * 2014 Lippincott Williams & Wilkins 425

5 Duron et al. adult population raises concerns that similar results may be seen in the few children who survive to discharge. We report the largest retrospective study to date of the outcomes of children found to have no signs of life after blunt trauma. Despite the potential limitations of the study, we report that survival of pediatric blunt trauma patients in the field without signs of life is dismal. Resuscitative thoracotomy poses a heightened risk of blood-borne pathogen exposure to involved health care workers and is associated with a significantly lower survival rate. AUTHORSHIP V.D. is responsible for the study concept and design. V.D., R.V.B., D.B., H.R.F., and J.S.U. acquired, analyzed, and interpreted the data. V.D. and R.V.B. drafted the manuscript, and D.B., H.R.F., and J.S.U. performed critical revision of the manuscript for important intellectual content. R.V.B. was responsible for the statistical supervision and analysis. J.S.U. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. DISCLOSURE The authors declare no conflicts of interest. REFERENCES 1. Hickey RW, Cohen DM, Strausbaugh S, Dietrich AM. Pediatric patients requiring CPR in the prehospital setting. Ann Emerg Med. 1995;25:495Y Haller JA. Pediatric trauma. The no. 1 killer of children. JAMA. 1983;249(1): Hunt PA, Greaves I, Owens WA. Emergency thoracotomy in thoracic traumava review. Injury. 2006;37:1Y Haller JA. The evolution and current status of emergency medical services for children. Surg Clin North Am. 2002;82:263Y Shimazu S, Shatney CH. Outcomes of trauma patients with no vital signs on hospital admission. J Trauma. 1983;23:213Y Stratton SJ, Brickett K, Crammer T. Prehospital pulseless, unconscious penetrating trauma victims: field assessments associated with survival. JTrauma. 1998;45:96Y Hopson LR, Hirsh E, Delgado J, Domeier RM, McSwain NE, Krohmer J. Guidelines for withholding or termination of resuscitation in prehospital traumatic cardiopulmonary arrest: joint position statement of the National Association of EMS Physicians and the American College of Surgeons Committee on Trauma. J Am Coll Surg. 2003;196(1):106Y Calkins CM, Bensard DD, Partrick DA, Karrer FM. A critical analysis of outcome for children sustaining cardiac arrest after blunt trauma. J Pediatr Surg. 2002;37(2):180Y Fisher B, Worthen M. Cardiac arrest induced by blunt trauma in children. Pediatr Emerg Care. 1999;15(4):274Y Hazinski MR, Chahine AA, Holcomb GW. Outcome of cardiovascular collapse in pediatric blunt trauma. Ann Emerg Med. 1994;23:1229Y Suominen P, Räsänen J, Kivioja A. Efficacy of cardiopulmonary resuscitation in pulseless paediatric trauma patients. Resuscitation. 1998;36:9Y Eichelberger MR, Randolph JG. Progress in pediatric trauma. World J Surg. 1985;9(2):222Y Beaver BL, Colombani PM, Buck JR, Dudgeon DL, Bohrer SL, Haller JA Jr. Efficacy of emergency room thoracotomy in pediatric trauma. JPediatrSurg. 1987;22(1):19Y Hofbauer M, Hüpfl M, Figl M, Kdolsky R. Retrospective analysis of emergency room thoracotomy in pediatric severe trauma patients. Resuscitation. 2011;82(2):185Y Rothenberg SS, Moore EE, Moore FA, Baxter BT, Moore JB, Cleveland HC. Emergency Department thoracotomy in childrenva critical analysis. JTrauma. 1989;29(10):1322Y Sheikh AA, Culbertson CB. Emergency department thoracotomy in children: rationale for selective application. J Trauma. 1993;34(3):323Y Rosemurgy AS, Norris PA, Olson SM, Hurst JM, Albrink MH. Prehospital traumatic cardiac arrest: the cost of futility. J Trauma. 1993;35(3):468Y Battistella FD, Nugent W, Owings JT, Anderson JT. Field triage of the pulseless trauma patient. Arch Surg. 1999;134(7):742Y745; discussion 745Y Capizzani AR, Drongowski R, Ehrlich PF. Assessment of termination of trauma resuscitation guidelines: are children small adults? J Pediatr Surg. 2010;45(5):903Y Biffl WL, Moore EE, Harken AH. Emergency department thoracotomy. In: Mattox KL, Feliciano DV, Moore EE, eds. Trauma. 4th ed. New York, NY: McGraw-Hill; Esposito TJ, Jurkovich GJ, Rice CL, Maier RV, Copass MK, Ashbaugh DG. Reappraisal of emergency room thoracotomy in a changing environment. JTrauma. 1991;31(7):881Y885 discussion 885Y Sloan EP, McGill BA, Zalenski R, Tsui P, Chen EH, Duda J, et al. Human immunodeficiency virus and hepatitis B virus seroprevalence in an urban trauma population. J Trauma. 1995;38(5):736Y Daniels D, Grytdal S, Wasley A; Centers for Disease Control and Prevention. Surveillance for acute viral hepatitisvunited States, MMWR Surveill Summ. 2009;58(3):1Y * 2014 Lippincott Williams & Wilkins