PRE-HOSPITAL INTERVENTIONS IN SEVERELY INJURED PEDIATRIC PATIENTS: RETHINKING THE ABC’s.

Kyle K Sokol, MD1, G E Black, MD1, K S Azarow, MD2, W Long, MD3, Matthew J Eckert, MD1, Matthew J Martin, MD1. 1Madigan Army Medical Center, 2Oregon Heath and Science University, 3Legacy Emanuel Medical Center

OBJECTIVES: The current conflict in Afghanistan has resulted in a high volume of significantly injured pediatric patients. The austere environment has demanded an emphasis on pre-hospital interventions (PHI) to sustain casualties during transport, but little is known about the epidemiology and effectiveness of PHI in the pediatric population.

METHODS: The Department of Defense Trauma Registry (DoDTR) was queried for all pediatric patients (<18 years) treated at Camp Bastion from 2004 to 2012. PHI were grouped by ATLS primary survey categories into 1) Airway – intubation or surgical airway, 2) Breathing – chest tube or needle thoracostomy, and 3) Circulation – tourniquet or hemostatic dressing application. Outcomes were assessed based on injury severity, hemodynamics, blood products and fluids, and mortality rates.

RESULTS: There were 766 injured children identified with 20% of requiring one or more PHI, most commonly Circulation (C, 59%) followed by Airway (A, 42%) and Breathing (B, 8%). The majority of C interventions were tourniquets (85%) and hemostatic dressings (15%). Only 35% of patients with extremity vascular injury or amputation received a C intervention, with a significant reduction in blood products and IV fluids associated with receiving a C PHI (Figure, both p<0.05). Airway interventions were most commonly endotracheal intubation for depressed mental status (GCS<8). Among patients with TBI (head AIS>/=3), A interventions were associated with higher unadjusted mortality (56% vs 20%, p<0.01), and remained independently associated with increased mortality after multivariate adjustment (OR 5.9, P=0.001). Breathing interventions were uncommon and only performed in 4% of patients with pneumo or hemothoraces, with no tension physiology on presentation, and no deaths or adverse outcomes.

CONCLUSION: There is a high incidence of PHI among pediatric patients with severe injuries in a combat setting. The most common and effective were Circulatory PHI for hemorrhage control, which should remain a primary focus of equipment and training. Airway interventions were most commonly performed in the setting of severe TBI, but were associated with worse outcomes and require further study to examine the indications and efficacy of the ABC approach in pediatric head trauma. Breathing interventions appear safe and effective, and may be under-utilized.

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