ORIGINAL ARTICLE
Surgical interventions for pediatric blast injury: An analysis from Afghanistan and Iraq 2002 to 2010 Mary J. Edwards, MD, Michael Lustik, MS, Terri Carlson, DO, Benjamin Tabak, MD, Douglas Farmer, MD, Kurt Edwards, MD, and Martin Eichelberger, MD, Honolulu, Hawaii
Acute blast injury requires aggressive operative intervention. This study documents therapeutic procedures required for children with blast injury in Afghanistan and Iraq from 2002 to 2010 at US military treatment facilities, to understand pediatric operative resources required after explosions. METHODS: The Joint Theatre Trauma Registry provides data for the previously mentioned population. The data were stratified by years of age as follows: 0 to 3, 4 to 8, 9 to 14, 15 to 19, older than 19 years. Therapeutic procedures were defined by DRG International Classification of DiseasesV9th Rev. codes 0 to 86.99. These were analyzed by age, body region, and Abbreviated Injury Scale (AIS) score. RESULTS: A total of 5,026 patients with a known age requiring a total of 22,677 therapeutic procedures were analyzed; 25% (n = 1,205) were children 14 years or younger. On average, 4.5 procedures were required per patient and varied significantly by age. Soft tissue debridement, vascular access procedure, laparotomy, and thoracostomy were the most common procedures for all ages. For all body regions, severe injury (AIS score Q 3) was associated with an increased need for an invasive procedure (30Y90%) in that region. Children 9 years to 14 years of age underwent significantly more procedures on average (5 procedures per patient) compared with adults (4.5 procedures per patient); children 3 years and younger underwent significantly less (3.15 procedures per patient). Children 4 years to 14 years of age were more likely than older patients to undergo a procedure for a severe head injury (40% vs. 29%), and those 9 years to 14 years old were more likely to undergo a procedure for severe thoracic injury (72%). After 4 years of age, procedures trend away from the head toward the extremity and amputation. CONCLUSION: Blast-injured children require significant operative resources during the acute phase of injury. In the event of an explosive attack, pediatric operative resources and expertise are required. (J Trauma Acute Care Surg. 2014;76: 854Y858. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. KEY WORDS: Pediatric; blast; treatment; explosion; surgery. BACKGROUND:
A
n explosion produces a unique, devastating spectrum of injury1 and is responsible for the majority of casualties in armed conflict and terrorist attacks.2 Children are frequently victims of the blast mechanism and require prompt surgical treatment to survive.3 Recent experience of pediatric blast injury in Afghanistan and Iraq revealed a higher incidence of head injury in children, a higher proportion of children with an Injury Severity Score (ISS) of greater than 15, and a trend toward increased mortality with decreasing age.4 Documentation of the operative requirements of children who sustain a blast injury provides a guide for preparation of personnel and of facilities to mitigate the impact of an explosion.
Submitted: July 8, 2013, Revised: August 20, 2013, Accepted: August 22, 2013. From the Departments of Surgery (M.J.E., T.C., B.T., D.F., K.E., M.E.) and Clinical Investigation (M.L.), Tripler Army Medical Center, Honolulu, Hawaii. This study was presented at the Pacific Association of Pediatric Surgeons Annual Meeting, April 2013, in Hunter Valley, Australia. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government. This study was conducted under a protocol reviewed and approved by the US Army Medical Research and Materiel Command Institutional Review Board and in accordance with the approved protocol. Address for reprints: Mary J. Edwards, MD, Department of Surgery, 1 Jarrett White Rd, Tripler Army Medical Center, Honolulu, HI 96859-5000; email: [email protected]. DOI: 10.1097/TA.0b013e3182aa2e66
854
PATIENTS AND METHODS The Joint Theatre Trauma Registry (JTTR) is a database, established in 2003 to document prospective information of all injured patients admitted to a US Department of Defense Medical Treatment Facility (MTF) at the Role 3 (combat hospital) echelon of care. Patient admission data to the facilities before 2003 were entered through retrospective chart review, and admissions after 2003 were prospectively collected. In 2006, data collection specialists were placed at Role 3 facilities in Afghanistan and Iraq to improve the quality of data in the registry. In this analysis, data from 2002 to 2010 (8 years) includes all local, noncoalition, civilian patients who were injured as a result of an explosive device such as an improvised explosive device, landmine, or unexploded ordinance. The DRG International Classification of DiseasesV9th Rev. (ICD-9) procedure codes from 0 to 86.99 (invasive procedures) for each patient were documented and stratified by age, ISS, Abbreviated Injury Scale (AIS) score, body region, and specific procedure performed. The number of procedures performed was analyzed on the square root scale to enhance normality. All ICD-9 surgical procedure codes (0Y86.99) were assigned a body region. Surgical procedures not specific to a body region, such as vascular access (2,844 procedures), or that did not represent an injury to a specific body region, such as J Trauma Acute Care Surg Volume 76, Number 3
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J Trauma Acute Care Surg Volume 76, Number 3
Edwards et al.
tracheostomy (290 procedures), were excluded from the body region analysis. Statistical analysis was accomplished using SAS software version 9.2 (SAS Institute Inc., Cary, NC). An analysis of variance was used to compare the mean number of procedures performed among age groups, and Tukey’s HSD was used to determine significance of post hoc pairwise comparisons. W2 tests were used to compare frequencies of procedures for an injury to a specific body region. This analysis was run separately for minor (AIS score 0Y2) and severe (AIS score 3Y6) injuries and only included procedures that were assigned to the body region injured. A significance level of p G 0.05 was used for all analyses.
RESULTS During 2002 to 2010, 4,928 patients met inclusion criteria with a known age. Of these, 1,213 were children 14 years or younger. The patients were stratified by age group for this analysis as follows: 0 year to 3 years (n = 164), 4 years to 8 years (n = 450), 9 years to 14 years (n = 599), 15 years to 19 years (n = 417), and older than 19 years (n = 3,298). In total 22,677 procedures were performed. The age breakdown is as follows: 444 procedures on children 0 year to 3 years, 2,069 on children 4 years to 8 years, 3,041 on children 9 years to 14 years, 1,953 on adolescents 15 years to 19 years, and 15,170 on adults older than 19 years. The mean and median number of procedures performed per patient during their hospitalization are documented in Table 1. Overall, the mean number of procedures per patient was 4.5, with a median of 4. This varied significantly by age, ranging from a mean of 3.2 surgical procedures per admission for the youngest patients (ages 0Y3 years) to a mean of 5.0 surgical procedures per admission for children aged 9 years to 14 years. The majority of patients required at least one invasive procedure as a result of their injury, and most required at least two. This also varied by age (Table 2). The most frequent procedures performed by age group are presented in Table 3. For all ages, skin and soft tissue
All ages 0Y3 4Y8 9Y14 15Y19 919
All Ages 0Y3 y 4Y8 y 9Y14 y 15Y19 y 919 y With Q1 procedure, % With Q2 procedures, %
87 75
80 65
88 77
92 80
91 79
86 74
debridement and wound closure were most common, followed by vascular access. Exploratory laparotomy or tube thoracostomy was the third or fourth most common, although this did vary by age. Infants and young children, 3 years and younger, most often required neurosurgical procedures, while extremity amputation and external fixation were more common in children older than 4 years. Skin grafting was commonly performed in patients during the age of 4 years. Fasciotomy was more commonly performed in children during the age of 9 years. Table 4 demonstrates the number and percentage of patients who received procedures by age and body region, stratified by injury severity. The injury severity is reflected in the AIS score, which varies from 0 (no injury) to 6 (lethal injury). Injuries 3 or greater are considered severe.5 Significant differences by age and injury location are evident. For no or minor injury (AIS score 0Y2), very young children (G3 years) were less likely to have procedures performed in all body regions except for the head where there was no significant difference by age. Schoolaged children (4Y14 years) were more likely than other groups to have procedures performed for similar nonsevere injuries to the chest, abdomen, and skin/soft tissue/burns. Severe injuries (AIS score 3Y6) were associated with a frequent requirement for operative intervention for all age groups and body regions (30Y90%). The 4-year-old to 14-year-old children were more likely than all others to have an operative intervention as a result of a head injury. Children younger than 9 years and especially very young children younger than 4 years were less likely to have a procedure performed for a severe chest injury. The remaining body regions face, abdomen, extremity, and skin/soft tissue/burn did not have age-related differences in the need for procedures performed to treat severe injury in that body region.
DISCUSSION
TABLE 1. Number of Procedures Age, y
TABLE 2. Patients Requiring Multiple Procedures
No. Patients
Mean
SD
Median
Minimum
Maximum
4,928 164 450 599 417 3,298
4.5 3.6 4.4 5.0 4.6 4.5
4.1 3.1 3.8 4.2 4.0 4.2
4 3 4 4 3 4
0 0 0 0 0 0
34 16 22 30 24 34
Overall p G 0.001 based on analysis of variance. Those age 0 year to 3 years had significantly fewer procedures compared with all other age groups. Those age 4 years to 8 years had significantly more than those age 0 year to 3 years. Those age 9 years to 14 years had significantly more than those age 0 year to 3 years and those older than 19 years. Those age 15 years to 19 years had significantly more than those age 0 year to 3 years. Those older than 19 years had significantly more than those age 0 year to 3 years and significantly less than those age 9 years to 14 years.
In industrialized Western nations, the common mechanism for pediatric trauma is blunt energy transfer to a child, which frequently requires nonoperative management. The recent increase in terror-related attacks on civilians and the history of recent armed conflicts result in the need to treat blast injury from multiple devices.4,6Y9 These include the improvised explosive device (stationary, vehicle born, or on a suicide bomber) and other exploding munitions such as a mortar or land mine placed near the homes of children, exposing them to life-threatening injury.8Y12 The current analysis documents the largest surgical treatment experience with blast injury to children in an austere environment. The results will prepare surgical teams for blast casualties to young patients, will encourage preparation of operative facilities for children, will help mitigate surgical
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856
Craniectomy (4)
Skin graft (6) Small intestinal resection (6) Tracheostomy (5) Small intestine anastomosis (5) Craniotomy (4)
Tracheostomy (290) Fasciotomy (289) Below-knee amputation (286) Removal soft tissue foreign body (273) Debridement open fx tib/fib (272) Ex fix Tib-Fib (244)
Amputation closure (379)
Exploratory laparotomy (480) Skin graft (414)
Central venous catheterization (66) Nonexcisional debridement (63) Excisional wound debridement (36) Skin/subcutaneous closure (29) Arterial catheterization (29) Exploratory laparotomy/ intestinal resection (17) Thoracostomy (17) Removal soft tissue foreign body (12) Ventriculostomy (7)
0Y3 y (n = 164)
Nonexcisional debridement (2,358) Central venous catheterization (1,965) Skin/subcutaneous closure (1,533) Excisional wound debridement (1,258) Arterial catheterization (879) Thoracostomy (719)
All (n = 4,928)
4Y8 y (n = 450)
Suture laceration eyebrow/lid (17)
Removal soft tissue foreign body (37) Debridement open fx tib/fib (25) Amputation closure (23) Abdominal washout (21) 2.02 elevate skull fx fragment (19) Craniectomy (18)
Thoracostomy (77) Exploratory laparotomy/ intestinal resection (58) Skin/subcutaneous closure (42) Skin graft (38)
Nonexcisional debridement (204) Central venous catheterization (172) Excisional wound debridement (118) Arterial catheterization (76)
TABLE 3. Frequently Performed Procedures by Age Group
Fasciotomy (29)
Below-knee amputation (41) 54.99 abdominal washout (33) Hemorrhage control NOS (32) Removal soft tissue foreign body (30) Finger amputation (29)
Amputation closure (50)
Exploratory laparotomy (70) Skin graft (67)
Nonexcisional debridement (313) Central venous catheterization (234) Excisional wound debridement (191) Skin/subcutaneous closure (158) Arterial catheterization (99) Thoracostomy (98)
9Y14 y (n = 599)
Debridement open fx tib/fib (22)
Ex fix tib/fib (22)
Below-knee amputation (33) Hemorrhage control NOS (28) Fasciotomy (25) Above-knee amputation (22)
Skin graft (37)
Thoracostomy (53) Amputation closure (41)
Nonexcisional debridement (236) Skin/subcutaneous closure (210) Central venous catheterization (167) Excisional wound debridement (120) Arterial catheterization (67) Exploratory laparotomy (55)
15Y19 y (n = 417)
Removal soft tissue foreign body (172)
Tracheostomy (236) Fasciotomy (223) Below-knee amputation (195) Debridement open fx tib/fib (195) Ex fix tib/fib (179)
Amputation closure (259)
Exploratory laparotomy (280) Skin graft (266)
Nonexcisional debridement (1,542) Central venous catheterization (1,326) Skin/subcutaneous closure (993) Excisional wound debridement (793) Arterial catheterization (608) Thoracostomy (474)
919 y (n = 3,298)
Edwards et al. J Trauma Acute Care Surg Volume 76, Number 3
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TABLE 4. Procedure Frequency by Body Region, Injury Severity, and Age AIS Score 0Y2
AIS Score 3Y6
BR
Age, y
Patients
Procedure
Requiring Procedure, %
p
Patients
Procedure
Requiring Procedure, %
p
1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 6 6 6 6 6 1 2 3 4 5 6
0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 All All All All All All
110 334 465 355 2,659 162 440 578 403 3,157 130 345 478 343 2,655 148 395 521 378 3,017 142 349 407 277 2,235 158 439 573 405 3,165 3,923 4,740 3,951 4,459 3,410 4,740
0 1 5 1 13 18 75 96 70 647 7 29 54 25 169 21 97 118 66 534 25 100 122 90 629 87 293 415 283 2,004 20 906 284 836 966 3,082
0.0 0.3 1.1 0.3 0.5 11.1 17.0 16.6 17.4 20.5 5.4 8.4 11.3 7.3 6.4 14.2 24.6 22.6 17.5 17.7 17.6 28.7 30.0 32.5 28.1 55.1 66.7 72.4 69.9 63.3 0.5 19.1 7.2 18.7 28.3 65.0
0.383
54 116 134 62 639 2 10 21 14 141 34 105 121 74 643 16 55 78 39 281 22 101 192 140 1,063 6 11 26 12 133 1,005 188 977 469 1,518 188
18 47 54 18 183 1 7 12 8 95 16 58 88 50 423 14 49 70 35 233 15 76 155 119 872 5 10 18 9 99 320 123 635 401 1,237 141
33.3 40.5 40.3 29.0 28.6 50.0 70.0 57.1 57.1 67.4 47.1 55.2 72.7 67.6 65.8 87.5 89.1 89.7 89.7 82.9 68.2 75.2 80.7 85.0 82.0 83.3 90.9 69.2 75.0 74.4 31.8 65.4 65.0 85.5 81.5 75.0
0.019
0.005
0.003
0.001
0.027
G0.001
0.809
0.012
0.429
0.158
0.701
BR, body region: 1, head/cervical spine; 2, face, 3, chest; 4, abdomen, 5, extremities; 6, external/burns.
complications, and will increase the potential for survival from a devastating injury. The number of operative procedures performed per patient varied by age. Children 9 years to 14 years of age had the highest number of operative interventions per patient. This group had the highest ISS (when analyzed as a continuous variable), the longest intensive care unit stay, and the longest hospital stay.3 The fewer operative procedures performed per patient for the youngest children (G4 years) are in contrast to an increased mortality and ISS of greater than 15 (severe).4 However, since the young children did not have as high an incidence of severe extremity injury,3 they were unlikely to undergo multiple, staged debridement as recommended in current military practice guidelines.13
The body region analysis reveals that children 0 year to 3 years of age were less likely than older children and young adults to undergo a surgical procedure for a severe head injury, despite a higher incidence of severe head injuries in this group.4 In comparison, older children, 4 years to 14 years of age, were more likely to have an operative intervention for a head injury compared with adults or teens older than 15 years. Children younger than 8 years were significantly less likely to have a surgical procedure for a severe thoracic injury, and this was especially notable with the youngest age group (G4 years). Previous analysis of this cohort reveals no significant change in the likelihood of thoracic injury with age.4 By far, the most common intervention for any thoracic injury in any age group was tube thoracostomy.
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An MTF in an austere environment is primarily staffed by general and orthopedic surgeons as well as other specialists, nurses, and ancillary staff who are accustomed to caring for adult patients. The education of each in care of children and the availability of equipment to treat young patients with a blast injury are variable. The analysis suggests the need for universal education of care for injured children, for appropriate equipment to perform surgery on young patients, and for resources, to care for children of all ages, especially 0 year to 3 years of age. Understanding the pattern of pediatric blast injury and anticipation of the operative requirements for surgical care will enhance outcome in an austere environment and improve performance of the surgical care team. Several limitations to this analysis exist. First, restrictions on humanitarian admissions to an MTF by the Department of Defense result in a selection bias that affects the severity of injury in the analysis. Humanitarian treatment of civilians at a military medical facility is permissible only if the injury is a result of the conflict or an immediate threat to life, limb, or eyesight. The second limitation is the common practice for families to travel a long distance to an MTF for evaluation and for treatment. Children who succumb during the journey are not entered into the JTTR. The third limitation is variation in data collection. In 2006, dedicated data collection personnel were stationed at every Role 3 medical facility. Consequently, from 2002 to 2006, consistent and complete data entry for each patient did not occur. As an example, 98 patients of the original 5,026 were excluded from the analysis because the medical record lacked a specific age. The fourth limitation is in the grouping of the surgical procedures into body region. The ICD-9 surgical procedure codes do not easily stratify by body region as designated by the AIS system. For example, the tracheostomy ICD-9 procedure code assigns it to the thorax and not the neck. In clinical practice, tracheostomy is often performed as a result of severe injury to a variety of body regions. The JTTR only captures patients evaluated at facilities providing the highest level of care (Role 3) by the United States within Iraq and Afghanistan. In conclusion, this analysis reveals that children with blast injury require frequent operative intervention. Children younger than 3 years did not receive operative treatment of severe blast injury comparable with the older age groups, although injury severity and mortality were higher (Edwards MJ, Lustik M, unpublished data). Factors that influence the change in practice for the youngest age group are fewer extremity injuries, absence of age-appropriate equipment, and few personnel who are pediatric specialists. As with adults, the most common procedures performed on children as a result of blast injury are soft tissue debridement, wound closure, vascular access, tube thoracostomy, and laparotomy. For those older than 4 years, amputation of an extremity is common. Documentation of the surgical operative needs of children who sustain a blast injury permits the development of plans to provide appropriate surgical
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care, to guarantee of age-appropriate surgical equipment, and to provide predeployment education of the personnel who will provide humanitarian, surgical care. ACKNOWLEDGMENTS The authors wish to acknowledge the Childress Institute for its in education and awareness of pediatric blast injury.
AUTHORSHIP M.J.E. contributed in the literature search, study design, data collection, data analysis, data interpretation, writing, and critical revision. M.L. contributed in the data analysis and data interpretation. T.C. contributed in the data analysis, literature search, and writing. B.T. contributed in the literature search and writing. D.F. contributed in the literature search and writing. M.E. contributed in the writing and critical revision K.E. contributed in the critical revision.
DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Champion HR, Holcomb JB, Young LA. Injuries from explosions: physics, biophysics and required research focus. J Trauma. 2009;66:1469Y1477. 2. Owens BD, et al. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 2008;64:295Y299. 3. Jaffe DH, Peleg K; Israel Trauma Group. Terror explosive injuries: a comparison of children, adolescents, and adults. Ann Surg. 2010;251(1):138Y143. 4. Edwards MJ, Lustik M, Eicherberger MR, Elster EA, Azarow K, Coppola C. Blast injury in children: an analysis from Afghanistan and Iraq, 2002Y2010. J Trauma Acute Care Surg. 2012;73:1278Y1283. 5. Baker SP, O’Neill B, Haddon W Jr, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187Y196. 6. Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Seminar: blast injuries. Lancet. 2009;374:405Y415. 7. Biddinger PD, Baggish A, Harrington L, d’Hemecort P, Hooley J, Jones J, Troyanos C, Dyer KS. Be preparedVthe Boston Marathon and masscasualty events. N Engl J Med. 2013;368:1958Y1960. 8. Biluka OO, Laurenge H, Danee L, Subedi KP, Becknell K. Injuries and deaths due to victim-activated improvised explosive devices, landmines and other explosive remnants of war in Nepal. Inj Prev. 2011;17(5):326Y331. 9. Almogy G, Rivkind AI. Terror in the 21st century: milestones and prospectsVpart I. Current Prob Surg. 2007;44:496Y554. 10. UNICEF in emergencies and humanitarian action. Available at: http:// www.unicef.org/emergencies/index_landmines.html. Accessed June 12, 2013. 11. Bilukha OO, Brennan M, Anderson M, Tsitsaev Z, Murtazaeva E, Ibragimov R. Seen but not heard: injuries and deaths from landmines and unexploded ordnance in Chechnya, 1994Y2005. Prehosp Disaster Med. 2007;22(6):507Y512. 12. Bilukha OO, Brennan M, Anderson M. The lasting legacy of war: epidemiology of injuries from landmines and unexploded ordnance in Afghanistan, 2002Y2006. Prehosp Disaster Med. 2008;23(6):493Y499. 13. United States Army Institute of Surgical Research Clinical Practice Guidelines. # 27. Management of War Wounds. Available at: http://www.usaisr.amedd.army.mil/ clinical_practice_guidelines.html. Accessed June 12, 2013.
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Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Surgical interventions for pediatric blast injury: An analysis from Afghanistan and Iraq 2002 to 2010 Mary J. Edwards, MD, Michael Lustik, MS, Terri Carlson, DO, Benjamin Tabak, MD, Douglas Farmer, MD, Kurt Edwards, MD, and Martin Eichelberger, MD, Honolulu, Hawaii
Acute blast injury requires aggressive operative intervention. This study documents therapeutic procedures required for children with blast injury in Afghanistan and Iraq from 2002 to 2010 at US military treatment facilities, to understand pediatric operative resources required after explosions. METHODS: The Joint Theatre Trauma Registry provides data for the previously mentioned population. The data were stratified by years of age as follows: 0 to 3, 4 to 8, 9 to 14, 15 to 19, older than 19 years. Therapeutic procedures were defined by DRG International Classification of DiseasesV9th Rev. codes 0 to 86.99. These were analyzed by age, body region, and Abbreviated Injury Scale (AIS) score. RESULTS: A total of 5,026 patients with a known age requiring a total of 22,677 therapeutic procedures were analyzed; 25% (n = 1,205) were children 14 years or younger. On average, 4.5 procedures were required per patient and varied significantly by age. Soft tissue debridement, vascular access procedure, laparotomy, and thoracostomy were the most common procedures for all ages. For all body regions, severe injury (AIS score Q 3) was associated with an increased need for an invasive procedure (30Y90%) in that region. Children 9 years to 14 years of age underwent significantly more procedures on average (5 procedures per patient) compared with adults (4.5 procedures per patient); children 3 years and younger underwent significantly less (3.15 procedures per patient). Children 4 years to 14 years of age were more likely than older patients to undergo a procedure for a severe head injury (40% vs. 29%), and those 9 years to 14 years old were more likely to undergo a procedure for severe thoracic injury (72%). After 4 years of age, procedures trend away from the head toward the extremity and amputation. CONCLUSION: Blast-injured children require significant operative resources during the acute phase of injury. In the event of an explosive attack, pediatric operative resources and expertise are required. (J Trauma Acute Care Surg. 2014;76: 854Y858. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Epidemiologic study, level III. KEY WORDS: Pediatric; blast; treatment; explosion; surgery. BACKGROUND:
A
n explosion produces a unique, devastating spectrum of injury1 and is responsible for the majority of casualties in armed conflict and terrorist attacks.2 Children are frequently victims of the blast mechanism and require prompt surgical treatment to survive.3 Recent experience of pediatric blast injury in Afghanistan and Iraq revealed a higher incidence of head injury in children, a higher proportion of children with an Injury Severity Score (ISS) of greater than 15, and a trend toward increased mortality with decreasing age.4 Documentation of the operative requirements of children who sustain a blast injury provides a guide for preparation of personnel and of facilities to mitigate the impact of an explosion.
Submitted: July 8, 2013, Revised: August 20, 2013, Accepted: August 22, 2013. From the Departments of Surgery (M.J.E., T.C., B.T., D.F., K.E., M.E.) and Clinical Investigation (M.L.), Tripler Army Medical Center, Honolulu, Hawaii. This study was presented at the Pacific Association of Pediatric Surgeons Annual Meeting, April 2013, in Hunter Valley, Australia. The views expressed in this publication are those of the author(s) and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government. This study was conducted under a protocol reviewed and approved by the US Army Medical Research and Materiel Command Institutional Review Board and in accordance with the approved protocol. Address for reprints: Mary J. Edwards, MD, Department of Surgery, 1 Jarrett White Rd, Tripler Army Medical Center, Honolulu, HI 96859-5000; email: [email protected]. DOI: 10.1097/TA.0b013e3182aa2e66
854
PATIENTS AND METHODS The Joint Theatre Trauma Registry (JTTR) is a database, established in 2003 to document prospective information of all injured patients admitted to a US Department of Defense Medical Treatment Facility (MTF) at the Role 3 (combat hospital) echelon of care. Patient admission data to the facilities before 2003 were entered through retrospective chart review, and admissions after 2003 were prospectively collected. In 2006, data collection specialists were placed at Role 3 facilities in Afghanistan and Iraq to improve the quality of data in the registry. In this analysis, data from 2002 to 2010 (8 years) includes all local, noncoalition, civilian patients who were injured as a result of an explosive device such as an improvised explosive device, landmine, or unexploded ordinance. The DRG International Classification of DiseasesV9th Rev. (ICD-9) procedure codes from 0 to 86.99 (invasive procedures) for each patient were documented and stratified by age, ISS, Abbreviated Injury Scale (AIS) score, body region, and specific procedure performed. The number of procedures performed was analyzed on the square root scale to enhance normality. All ICD-9 surgical procedure codes (0Y86.99) were assigned a body region. Surgical procedures not specific to a body region, such as vascular access (2,844 procedures), or that did not represent an injury to a specific body region, such as J Trauma Acute Care Surg Volume 76, Number 3
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
J Trauma Acute Care Surg Volume 76, Number 3
Edwards et al.
tracheostomy (290 procedures), were excluded from the body region analysis. Statistical analysis was accomplished using SAS software version 9.2 (SAS Institute Inc., Cary, NC). An analysis of variance was used to compare the mean number of procedures performed among age groups, and Tukey’s HSD was used to determine significance of post hoc pairwise comparisons. W2 tests were used to compare frequencies of procedures for an injury to a specific body region. This analysis was run separately for minor (AIS score 0Y2) and severe (AIS score 3Y6) injuries and only included procedures that were assigned to the body region injured. A significance level of p G 0.05 was used for all analyses.
RESULTS During 2002 to 2010, 4,928 patients met inclusion criteria with a known age. Of these, 1,213 were children 14 years or younger. The patients were stratified by age group for this analysis as follows: 0 year to 3 years (n = 164), 4 years to 8 years (n = 450), 9 years to 14 years (n = 599), 15 years to 19 years (n = 417), and older than 19 years (n = 3,298). In total 22,677 procedures were performed. The age breakdown is as follows: 444 procedures on children 0 year to 3 years, 2,069 on children 4 years to 8 years, 3,041 on children 9 years to 14 years, 1,953 on adolescents 15 years to 19 years, and 15,170 on adults older than 19 years. The mean and median number of procedures performed per patient during their hospitalization are documented in Table 1. Overall, the mean number of procedures per patient was 4.5, with a median of 4. This varied significantly by age, ranging from a mean of 3.2 surgical procedures per admission for the youngest patients (ages 0Y3 years) to a mean of 5.0 surgical procedures per admission for children aged 9 years to 14 years. The majority of patients required at least one invasive procedure as a result of their injury, and most required at least two. This also varied by age (Table 2). The most frequent procedures performed by age group are presented in Table 3. For all ages, skin and soft tissue
All ages 0Y3 4Y8 9Y14 15Y19 919
All Ages 0Y3 y 4Y8 y 9Y14 y 15Y19 y 919 y With Q1 procedure, % With Q2 procedures, %
87 75
80 65
88 77
92 80
91 79
86 74
debridement and wound closure were most common, followed by vascular access. Exploratory laparotomy or tube thoracostomy was the third or fourth most common, although this did vary by age. Infants and young children, 3 years and younger, most often required neurosurgical procedures, while extremity amputation and external fixation were more common in children older than 4 years. Skin grafting was commonly performed in patients during the age of 4 years. Fasciotomy was more commonly performed in children during the age of 9 years. Table 4 demonstrates the number and percentage of patients who received procedures by age and body region, stratified by injury severity. The injury severity is reflected in the AIS score, which varies from 0 (no injury) to 6 (lethal injury). Injuries 3 or greater are considered severe.5 Significant differences by age and injury location are evident. For no or minor injury (AIS score 0Y2), very young children (G3 years) were less likely to have procedures performed in all body regions except for the head where there was no significant difference by age. Schoolaged children (4Y14 years) were more likely than other groups to have procedures performed for similar nonsevere injuries to the chest, abdomen, and skin/soft tissue/burns. Severe injuries (AIS score 3Y6) were associated with a frequent requirement for operative intervention for all age groups and body regions (30Y90%). The 4-year-old to 14-year-old children were more likely than all others to have an operative intervention as a result of a head injury. Children younger than 9 years and especially very young children younger than 4 years were less likely to have a procedure performed for a severe chest injury. The remaining body regions face, abdomen, extremity, and skin/soft tissue/burn did not have age-related differences in the need for procedures performed to treat severe injury in that body region.
DISCUSSION
TABLE 1. Number of Procedures Age, y
TABLE 2. Patients Requiring Multiple Procedures
No. Patients
Mean
SD
Median
Minimum
Maximum
4,928 164 450 599 417 3,298
4.5 3.6 4.4 5.0 4.6 4.5
4.1 3.1 3.8 4.2 4.0 4.2
4 3 4 4 3 4
0 0 0 0 0 0
34 16 22 30 24 34
Overall p G 0.001 based on analysis of variance. Those age 0 year to 3 years had significantly fewer procedures compared with all other age groups. Those age 4 years to 8 years had significantly more than those age 0 year to 3 years. Those age 9 years to 14 years had significantly more than those age 0 year to 3 years and those older than 19 years. Those age 15 years to 19 years had significantly more than those age 0 year to 3 years. Those older than 19 years had significantly more than those age 0 year to 3 years and significantly less than those age 9 years to 14 years.
In industrialized Western nations, the common mechanism for pediatric trauma is blunt energy transfer to a child, which frequently requires nonoperative management. The recent increase in terror-related attacks on civilians and the history of recent armed conflicts result in the need to treat blast injury from multiple devices.4,6Y9 These include the improvised explosive device (stationary, vehicle born, or on a suicide bomber) and other exploding munitions such as a mortar or land mine placed near the homes of children, exposing them to life-threatening injury.8Y12 The current analysis documents the largest surgical treatment experience with blast injury to children in an austere environment. The results will prepare surgical teams for blast casualties to young patients, will encourage preparation of operative facilities for children, will help mitigate surgical
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855
856
Craniectomy (4)
Skin graft (6) Small intestinal resection (6) Tracheostomy (5) Small intestine anastomosis (5) Craniotomy (4)
Tracheostomy (290) Fasciotomy (289) Below-knee amputation (286) Removal soft tissue foreign body (273) Debridement open fx tib/fib (272) Ex fix Tib-Fib (244)
Amputation closure (379)
Exploratory laparotomy (480) Skin graft (414)
Central venous catheterization (66) Nonexcisional debridement (63) Excisional wound debridement (36) Skin/subcutaneous closure (29) Arterial catheterization (29) Exploratory laparotomy/ intestinal resection (17) Thoracostomy (17) Removal soft tissue foreign body (12) Ventriculostomy (7)
0Y3 y (n = 164)
Nonexcisional debridement (2,358) Central venous catheterization (1,965) Skin/subcutaneous closure (1,533) Excisional wound debridement (1,258) Arterial catheterization (879) Thoracostomy (719)
All (n = 4,928)
4Y8 y (n = 450)
Suture laceration eyebrow/lid (17)
Removal soft tissue foreign body (37) Debridement open fx tib/fib (25) Amputation closure (23) Abdominal washout (21) 2.02 elevate skull fx fragment (19) Craniectomy (18)
Thoracostomy (77) Exploratory laparotomy/ intestinal resection (58) Skin/subcutaneous closure (42) Skin graft (38)
Nonexcisional debridement (204) Central venous catheterization (172) Excisional wound debridement (118) Arterial catheterization (76)
TABLE 3. Frequently Performed Procedures by Age Group
Fasciotomy (29)
Below-knee amputation (41) 54.99 abdominal washout (33) Hemorrhage control NOS (32) Removal soft tissue foreign body (30) Finger amputation (29)
Amputation closure (50)
Exploratory laparotomy (70) Skin graft (67)
Nonexcisional debridement (313) Central venous catheterization (234) Excisional wound debridement (191) Skin/subcutaneous closure (158) Arterial catheterization (99) Thoracostomy (98)
9Y14 y (n = 599)
Debridement open fx tib/fib (22)
Ex fix tib/fib (22)
Below-knee amputation (33) Hemorrhage control NOS (28) Fasciotomy (25) Above-knee amputation (22)
Skin graft (37)
Thoracostomy (53) Amputation closure (41)
Nonexcisional debridement (236) Skin/subcutaneous closure (210) Central venous catheterization (167) Excisional wound debridement (120) Arterial catheterization (67) Exploratory laparotomy (55)
15Y19 y (n = 417)
Removal soft tissue foreign body (172)
Tracheostomy (236) Fasciotomy (223) Below-knee amputation (195) Debridement open fx tib/fib (195) Ex fix tib/fib (179)
Amputation closure (259)
Exploratory laparotomy (280) Skin graft (266)
Nonexcisional debridement (1,542) Central venous catheterization (1,326) Skin/subcutaneous closure (993) Excisional wound debridement (793) Arterial catheterization (608) Thoracostomy (474)
919 y (n = 3,298)
Edwards et al. J Trauma Acute Care Surg Volume 76, Number 3
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J Trauma Acute Care Surg Volume 76, Number 3
Edwards et al.
TABLE 4. Procedure Frequency by Body Region, Injury Severity, and Age AIS Score 0Y2
AIS Score 3Y6
BR
Age, y
Patients
Procedure
Requiring Procedure, %
p
Patients
Procedure
Requiring Procedure, %
p
1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 6 6 6 6 6 1 2 3 4 5 6
0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 0Y3 4Y8 9Y14 15Y19 919 All All All All All All
110 334 465 355 2,659 162 440 578 403 3,157 130 345 478 343 2,655 148 395 521 378 3,017 142 349 407 277 2,235 158 439 573 405 3,165 3,923 4,740 3,951 4,459 3,410 4,740
0 1 5 1 13 18 75 96 70 647 7 29 54 25 169 21 97 118 66 534 25 100 122 90 629 87 293 415 283 2,004 20 906 284 836 966 3,082
0.0 0.3 1.1 0.3 0.5 11.1 17.0 16.6 17.4 20.5 5.4 8.4 11.3 7.3 6.4 14.2 24.6 22.6 17.5 17.7 17.6 28.7 30.0 32.5 28.1 55.1 66.7 72.4 69.9 63.3 0.5 19.1 7.2 18.7 28.3 65.0
0.383
54 116 134 62 639 2 10 21 14 141 34 105 121 74 643 16 55 78 39 281 22 101 192 140 1,063 6 11 26 12 133 1,005 188 977 469 1,518 188
18 47 54 18 183 1 7 12 8 95 16 58 88 50 423 14 49 70 35 233 15 76 155 119 872 5 10 18 9 99 320 123 635 401 1,237 141
33.3 40.5 40.3 29.0 28.6 50.0 70.0 57.1 57.1 67.4 47.1 55.2 72.7 67.6 65.8 87.5 89.1 89.7 89.7 82.9 68.2 75.2 80.7 85.0 82.0 83.3 90.9 69.2 75.0 74.4 31.8 65.4 65.0 85.5 81.5 75.0
0.019
0.005
0.003
0.001
0.027
G0.001
0.809
0.012
0.429
0.158
0.701
BR, body region: 1, head/cervical spine; 2, face, 3, chest; 4, abdomen, 5, extremities; 6, external/burns.
complications, and will increase the potential for survival from a devastating injury. The number of operative procedures performed per patient varied by age. Children 9 years to 14 years of age had the highest number of operative interventions per patient. This group had the highest ISS (when analyzed as a continuous variable), the longest intensive care unit stay, and the longest hospital stay.3 The fewer operative procedures performed per patient for the youngest children (G4 years) are in contrast to an increased mortality and ISS of greater than 15 (severe).4 However, since the young children did not have as high an incidence of severe extremity injury,3 they were unlikely to undergo multiple, staged debridement as recommended in current military practice guidelines.13
The body region analysis reveals that children 0 year to 3 years of age were less likely than older children and young adults to undergo a surgical procedure for a severe head injury, despite a higher incidence of severe head injuries in this group.4 In comparison, older children, 4 years to 14 years of age, were more likely to have an operative intervention for a head injury compared with adults or teens older than 15 years. Children younger than 8 years were significantly less likely to have a surgical procedure for a severe thoracic injury, and this was especially notable with the youngest age group (G4 years). Previous analysis of this cohort reveals no significant change in the likelihood of thoracic injury with age.4 By far, the most common intervention for any thoracic injury in any age group was tube thoracostomy.
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J Trauma Acute Care Surg Volume 76, Number 3
Edwards et al.
An MTF in an austere environment is primarily staffed by general and orthopedic surgeons as well as other specialists, nurses, and ancillary staff who are accustomed to caring for adult patients. The education of each in care of children and the availability of equipment to treat young patients with a blast injury are variable. The analysis suggests the need for universal education of care for injured children, for appropriate equipment to perform surgery on young patients, and for resources, to care for children of all ages, especially 0 year to 3 years of age. Understanding the pattern of pediatric blast injury and anticipation of the operative requirements for surgical care will enhance outcome in an austere environment and improve performance of the surgical care team. Several limitations to this analysis exist. First, restrictions on humanitarian admissions to an MTF by the Department of Defense result in a selection bias that affects the severity of injury in the analysis. Humanitarian treatment of civilians at a military medical facility is permissible only if the injury is a result of the conflict or an immediate threat to life, limb, or eyesight. The second limitation is the common practice for families to travel a long distance to an MTF for evaluation and for treatment. Children who succumb during the journey are not entered into the JTTR. The third limitation is variation in data collection. In 2006, dedicated data collection personnel were stationed at every Role 3 medical facility. Consequently, from 2002 to 2006, consistent and complete data entry for each patient did not occur. As an example, 98 patients of the original 5,026 were excluded from the analysis because the medical record lacked a specific age. The fourth limitation is in the grouping of the surgical procedures into body region. The ICD-9 surgical procedure codes do not easily stratify by body region as designated by the AIS system. For example, the tracheostomy ICD-9 procedure code assigns it to the thorax and not the neck. In clinical practice, tracheostomy is often performed as a result of severe injury to a variety of body regions. The JTTR only captures patients evaluated at facilities providing the highest level of care (Role 3) by the United States within Iraq and Afghanistan. In conclusion, this analysis reveals that children with blast injury require frequent operative intervention. Children younger than 3 years did not receive operative treatment of severe blast injury comparable with the older age groups, although injury severity and mortality were higher (Edwards MJ, Lustik M, unpublished data). Factors that influence the change in practice for the youngest age group are fewer extremity injuries, absence of age-appropriate equipment, and few personnel who are pediatric specialists. As with adults, the most common procedures performed on children as a result of blast injury are soft tissue debridement, wound closure, vascular access, tube thoracostomy, and laparotomy. For those older than 4 years, amputation of an extremity is common. Documentation of the surgical operative needs of children who sustain a blast injury permits the development of plans to provide appropriate surgical
858
care, to guarantee of age-appropriate surgical equipment, and to provide predeployment education of the personnel who will provide humanitarian, surgical care. ACKNOWLEDGMENTS The authors wish to acknowledge the Childress Institute for its in education and awareness of pediatric blast injury.
AUTHORSHIP M.J.E. contributed in the literature search, study design, data collection, data analysis, data interpretation, writing, and critical revision. M.L. contributed in the data analysis and data interpretation. T.C. contributed in the data analysis, literature search, and writing. B.T. contributed in the literature search and writing. D.F. contributed in the literature search and writing. M.E. contributed in the writing and critical revision K.E. contributed in the critical revision.
DISCLOSURE The authors declare no conflicts of interest.
REFERENCES 1. Champion HR, Holcomb JB, Young LA. Injuries from explosions: physics, biophysics and required research focus. J Trauma. 2009;66:1469Y1477. 2. Owens BD, et al. Combat wounds in Operation Iraqi Freedom and Operation Enduring Freedom. J Trauma. 2008;64:295Y299. 3. Jaffe DH, Peleg K; Israel Trauma Group. Terror explosive injuries: a comparison of children, adolescents, and adults. Ann Surg. 2010;251(1):138Y143. 4. Edwards MJ, Lustik M, Eicherberger MR, Elster EA, Azarow K, Coppola C. Blast injury in children: an analysis from Afghanistan and Iraq, 2002Y2010. J Trauma Acute Care Surg. 2012;73:1278Y1283. 5. Baker SP, O’Neill B, Haddon W Jr, Long WB. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14:187Y196. 6. Wolf SJ, Bebarta VS, Bonnett CJ, Pons PT, Cantrill SV. Seminar: blast injuries. Lancet. 2009;374:405Y415. 7. Biddinger PD, Baggish A, Harrington L, d’Hemecort P, Hooley J, Jones J, Troyanos C, Dyer KS. Be preparedVthe Boston Marathon and masscasualty events. N Engl J Med. 2013;368:1958Y1960. 8. Biluka OO, Laurenge H, Danee L, Subedi KP, Becknell K. Injuries and deaths due to victim-activated improvised explosive devices, landmines and other explosive remnants of war in Nepal. Inj Prev. 2011;17(5):326Y331. 9. Almogy G, Rivkind AI. Terror in the 21st century: milestones and prospectsVpart I. Current Prob Surg. 2007;44:496Y554. 10. UNICEF in emergencies and humanitarian action. Available at: http:// www.unicef.org/emergencies/index_landmines.html. Accessed June 12, 2013. 11. Bilukha OO, Brennan M, Anderson M, Tsitsaev Z, Murtazaeva E, Ibragimov R. Seen but not heard: injuries and deaths from landmines and unexploded ordnance in Chechnya, 1994Y2005. Prehosp Disaster Med. 2007;22(6):507Y512. 12. Bilukha OO, Brennan M, Anderson M. The lasting legacy of war: epidemiology of injuries from landmines and unexploded ordnance in Afghanistan, 2002Y2006. Prehosp Disaster Med. 2008;23(6):493Y499. 13. United States Army Institute of Surgical Research Clinical Practice Guidelines. # 27. Management of War Wounds. Available at: http://www.usaisr.amedd.army.mil/ clinical_practice_guidelines.html. Accessed June 12, 2013.
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