1-s2.0-S0022346811001552-main

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Journal of Pediatric Surgery (2011) 46, 1564–1571

Epidemiology of pediatric cardiac injuries: a NationalTrauma Data Bank analysis☆

Yvonne E. Kaptein⁎, Peep Talving, Agathoklis Konstantinidis, Lydia Lam, Kenji Inaba,David Plurad, Demetrios Demetriades

Department of Surgery, Division of Acute Care Surgery at the Los Angeles County + University of Southern CaliforniaMedical Center, Los Angeles, CA, 90033, USA

Received 2 November 2010; revised 9 February 2011; accepted 10 February 2011

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Key words:Pediatric cardiac injury;Age-related outcomes;Morbidity;Mortality

AbstractBackground: Few studies of pediatric cardiac injuries have been conducted in large cohorts. We,therefore, investigated the epidemiology of these injuries in the United States.Methods: We identified patients with traumatic cardiac injury from the National Trauma Data Bank,using the International Classification of Diseases, Ninth Revision, codes. Demographic data, clinicaldata, and inhospital outcomes were compared among 5 age groups. A logistic regression model wasused to determine adjusted mortality among these groups.Results: Six hundred twenty-six patients met criteria. Fifty-nine percent sustained cardiac contusion;36%, laceration. Penetrating injuries proved more severe than blunt, having lower average GlasgowComa Scale (6.8 vs 8.7) and higher percentage of patients with Glasgow Coma Scale of 8 or lower (68%vs 53%). Associated injuries occurred in 484 (77%), most common being lung injuries (46%),hemopneumothorax (37%), and rib fractures (26%). Eleven percent underwent laparotomy; 9%,thoracotomy; 2%, craniotomy/craniectomy; and 0.2%, sternotomy. Complications occurred in 80 (13%),most common being cardiac arrest (4%). Firearm injuries result in the highest mortality rate (76%),compared with other mechanisms (26%-31%). Crude mortality in different age strata showed significantdifferences that were lost after adjustment for confounding variables.Conclusions: The predominant cardiac injury was blunt (65%; 35% sustained penetrating insults),frequently paired with contusion. Pediatric cardiac injury is associated with excessive inhospitalmortality (40%), with no age-related difference in adjusted mortality.© 2011 Elsevier Inc. All rights reserved.

☆ The purpose of this study was to delineate the epidemiology ofediatric cardiac trauma in the United States, as recorded in the Nationalrauma Data Bank, the largest trauma registry currently available.⁎ Corresponding author. University of Southern California, Keck

chool of Medicine, Department of Surgery, Division of Trauma andurgical Critical Care, Los Angeles County General Hospital (LAC + USC),os Angeles, CA, 90033-4525, USA.E-mail address: [email protected] (Y.E. Kaptein).

022-3468/$ – see front matter © 2011 Elsevier Inc. All rights reserved.oi:10.1016/j.jpedsurg.2011.02.041

Thoracic trauma may result in a variety of heart injuries,ranging from clinically insignificant myocardial contusionto instantly fatal laceration or rupture [1-7]. Multipleprevious studies have investigated cardiac injuries inchildren [1,3-6,8]; however, these examinations consist ofcase reports [1,9] or are limited by small patient populations[2,3,8,10-12]. The largest pediatric population studied todate consists of 184 children including patients suffering

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http://dx.doi.org/10.1016/j.jpedsurg.2011.02.041

1565Epidemiology of pediatric cardiac injuries: a NTDB analysis

solely from blunt cardiac injury [12]. Nevertheless, nocontemporary reviews exist pertinent to penetrating cardiaclesions in pediatric population.

1. Materials and methods

This is a National Trauma Data Bank (NTDB) analysisbased on Dataset version 7.0 containing 1,861,779 medicalrecords contributed by more than 900 trauma centers in theUnited States from 2002 to 2006. All data provided by theNTDB are maintained by the American College ofSurgeons and subjected to quality screening for consistencyand validity. The use of NTDB data is in strict compliancewith the Health Insurance Portability and AccountabilityAct of 1996.

The study population consisted of all patients youngerthan 18 years, diagnosed with at least 1 traumatic cardiac

Table 1 Demographic and injury characteristics according to age gro

Total(n = 626)

Infant (b1 y)(n = 10)

Toddl(1-3 y(n = 3

Male 75% (471/626) 80% (8/10) 60% (RaceWhite 48% (282/586) 60% (6/10) 43% (Black 24% (142/586) 10% (1/10) 17% (Hispanic 18% (105/586) 20% (2/10) 23% (Asian/Pacific Islanders 2% (10/586) 0% (0/10) 3% (Native American 0.9% (5/586) 0% (0/10) 3% (Other 7% (42/586) 10% (1/10) 10% (Injury siteStreet 48% (299/626) 30% (3/10) 27% (Home 10% (62/626) 30% (3/10) 47% (Public place 6% (36/626) 0% (0/10) 3% (Unknown 23% (141/626) 20% (2/10) 13% (Other 14% (88/626) 20% (2/10) 10% (Mechanism of injuryBlunt 65% (402/619) 78% (7/9) 77% (Penetrating 35% (214/619) 22% (2/9) 17% (Burn 0.5% (3/619) 0% (0/9) 7% (SBP b90 mm Hg 12% (51/419) 50% (2/4) 50% (GCS ≤8 59% (325/555) 67% (6/9) 72% (ISS (mean ± SD) 33.8 ± 21.2 41.4 ± 19.8 34.7 ±15-25 26% (164/626) 20% (2/10) 27% (N25 57% (355/626) 80% (8/10) 53% (Cardiac injuryContusion 59% (368/626) 70% (7/10) 70% (Laceration 36% (226/626) 30% (3/10) 33% (Unspecified/other 7% (44/626) 10% (1/10) 0% (Major surgical interventions

Exploratory laparotomy 11% (67/626) 10% (1/10) 17% (Resuscitative thoracotomy 9% (59/626) 10% (1/10) 3% (Craniotomy/craniectomy 2% (11/626) 0% (0/10) 3% (Sternotomy 0.2% (1/626) 0% (0/10) 0% (

P values were derived from χ2 analysis and indicate the probability that the obs

lesion. To identify these patients, we used the InternationalClassification of Diseases, Ninth Revision, codes forcardiac contusions (861.01 and 861.11), lacerations(861.02, 861.03, 861.12, and 861.13), and unspecifiedinjuries (861.00 and 861.10). Patients were subsequentlydivided into 5 age groups: infants (b1 year), toddlers (1-3years), preschool age (4-5 years), school age (6-12 years),and adolescents (13-17 years). These age divisions werechosen to reflect activity patterns and lifestyle changes seenin pediatric patients in the United States, which wepredicted might correlate with types of injuries sustained.Data collected included demographic and injury character-istics (sex, race, site and mechanism of injury, systolicblood pressure [SBP], and Glasgow Coma Scale [GCS]score on admission, Abbreviated Injury Scale, InjurySeverity Score [ISS], and surgical procedures performed),associated injuries (head, thoracic, and intra-abdominalinjuries), and complications.

up

er)0)

Preschool(4-5 y)(n = 23)

School (6-12 y)(n = 104)

Adolescent(13-17 y)(n = 459)

P

18/30) 57% (13/23) 60% (62/104) 81% (370/459) b.001.161

13/30) 32% (7/22) 46% (43/94) 50% (213/430)5/30) 27% (6/22) 30% (28/94) 24% (102/430)7/30) 14% (3/22) 12% (11/94) 19% (82/430)1/30) 0% (0/22) 3% (3/94) 1% (6/430)1/30) 5% (1/22) 1% (1/94) 0.5% (2/430)3/30) 23% (5/22) 9% (8/94) 6% (25/430)

b.0018/30) 30% (7/23) 45% (47/104) 51% (234/459)14/30) 13% (3/23) 12% (12/104) 7% (30/459)1/30) 4% (1/23) 10% (10/104) 5% (24/459)4/30) 35% (8/23) 20% (21/104) 23% (106/459)3/30) 17% (4/23) 13% (14/104) 14% (65/459)

b.00123/30) 78% (18/23) 80% (82/102) 60% (272/455)5/30) 22% (5/23) 20% (20/102) 40% (182/455)2/30) 0% (0/23) 0% (0/102) 0.2% (1/455)10/20) 12% (2/17) 9% (7/74) 10% (30/304) b.00121/29) 45% (9/20) 49% (44/89) 60% (245/408) .11322.4 25.7 ± 18.5 30.9 ± 20.4 34.6 ± 21.48/30) 39% (9/23) 23% (24/104) 26% (121/459) .60516/30) 39% (9/23) 54% (56/104) 58% (266/459) .208

21/30) 78% (18/23) 72% (75/104) 54% (247/459) .00110/30) 17% (4/23) 25% (26/104) 40% (183/459) .0160/30) 4% (1/23) 6% (6/104) 8% (36/459) .497

5/30) 9% (2/23) 5% (5/104) 12% (54/459) .2361/30) 4% (1/23) 9% (9/104) 10% (47/459) .6571/30) 0% (0/23) 1% (1/104) 2% (9/459) .8240/30) 0% (0/23) 0% (0/104) 0.2% (1/459) .985

erved distributions could be because of chance.

Blunt Cardiac Trauma

87.3%

10.0%4.7%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Contusion Laceration UnspecifiedType of Cardiac Injury

Per

cen

tag

e

Penetrating Cardiac Trauma

5.6%

86.0%

10.3%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Contusion Laceration UnspecifiedType of Cardiac Injury

Per

cen

tag

e A

B

Fig. 1 Types of cardiac injury in patient with blunt trauma (A),and penetrating trauma (B).

Table 2 Mortality based on the mechanism of injury

Total(n = 622)

Mortalityrate

P

Mechanism of injury b.001Firearm 140 76%Motor vehicle accident 291 31%

1566 Y.E. Kaptein et al.

Primary outcome was mortality, and secondary outcomesincluded hospital length of stay and intensive care unit lengthof stay (ICU-LOS). Contingency tables were created for eachdata set, and statistical analysis was performed using χ2 withYates correction or Fisher exact test for dichotomousvariables and analysis of variance (ANOVA) for continuousvariables. Categorical variables are described as percentagesof each age group falling under each category, with associatedP values. Continuous variables are described as mean ± SD.The younger age stratum (b1 year) was set as the referencepopulation to which the older age groups were compared,with respect to outcomes. To adjust for confounding factors, amultivariable logistic regression model was used; and theadjusted mortality between the remaining 4 age groups wascalculated. Factors significantly different between the 5 agegroups at a P b .05 level were entered into the regressionmodel. Odds ratio (OR) and 95% confidence interval werecalculated for each age group, with the younger group(b1 year) set as the reference population (OR, 1.0).

All statistical analyses were performed using the SPSS forWindows, version 12.0 (SPSS Inc, Chicago, IL).

Auto vs pedestrian 26 27%Fall 8 25%Other/unspecified/unknown 157 26%

Survival status is unknown for 4 patients (3 involved in motor vehicleaccidents and 1 other). P value was derived from χ2 analysis andindicates the probability that the distribution of survival vs mortalityfor mechanisms of injury could be because of chance.

2. Results

Overall, 626 patients met inclusion criteria, accountingfor 0.03% of all patients in the NTDB. Of these patients, 10

were infants (2%), 30 toddlers (5%), 23 preschoolers (4%),104 school-age children (17%), and 459 adolescents (73%).

A total of 75% of the study population were male; 48%were white; 24%, black; and 18%, Hispanic (Table 1). Themost common setting of injury was the street, where 48% oftotal injuries occurred. Adolescents incurred injuries in thissetting (51%) more frequently than did other age groups (P b.001). The second most common site of injury was adomestic setting, where 10% of injuries occurred, withtoddlers' injuries occurring here most frequently (47%; P b.001). The most common mechanism of injury was blunt,affecting 65% of all patients, with the rate of injury beingsignificantly higher in school-age children (80%; P b .001).

Overall, 12% of the patients were hypotensive (SBP, b90mmHg) on admission; and 59% sustained an associated severetraumatic brain injury (GCS ≤8). The mean ISS was 33.8 ±21.2, with 164 patients (26%) sustaining severe injuries (ISS,15-25) and 355 patients (57%) sustaining critical injuries (ISS,N25). The most common type of cardiac injury was contusion,affecting 59% of the population. The proportion of injuries thatare contusions is significantly higher in preschoolers (78%)comparedwith other age groups (P= .001). Cardiac lacerationsoccurred in 36%, with adolescents experiencing the greatestproportion of laceration vs other injuries (40%; P = .016)(Table 1). Among patients who sustained blunt trauma, most(87%) had cardiac contusion (Fig. 1A). Conversely, patientssustaining penetrating trauma were more likely to have heartlaceration (86%) (Fig. 1B).

Of those who sustained blunt injury and had known GCS,the average GCS score was 8.7 ± 5.6; of those who sustainedpenetrating injury, the average GCS score was 6.8 ± 5.5 (P b.001). Fifty-three percent (180/342) of blunt injury patientswith known GCS had a GCS score of 8 or lower, whereas68% (139/203) of penetrating injury patients had a GCSscore of 8 or lower (P b .001).

The most common surgical intervention was exploratorylaparotomy, performed on 11% of the pediatric population.Overall, 9% of patients underwent thoracotomy; 2%,craniotomy/craniectomy; and 0.2%, sternotomy (Table 1).Blunt trauma was sustained by 44 (66%) of those whounderwent laparotomy and by all patients who underwent

Table 3A Associated injuries based on age

Total (n = 626) Infant (b1 y)(n = 10)

Toddler (1-3 y)(n = 30)

Preschool (4-5 y)(n = 23)

School (6-12 y)(n = 104)

Adolescent (13-17 y)(n = 459)

P

Head injurySubarachnoidhemorrhage

13% (81/626) 40% (4/10) 20% (6/30) 13% (3/23) 16% (17/104) 11% (51/459) .036

Skull fracture 12% (74/626) 10% (1/10) 13% (4/30) 26% (6/23) 12% (12/104) 11% (51/459) .306Subduralhemorrhage

12% (72/626) 30% (3/10) 10% (3/30) 13% (3/23) 13% (14/104) 11% (49/459) .382

Epiduralhemorrhage

7% (42/626) 10% (1/10) 0% (0/30) 13% (3/23) 10% (10/104) 6% (28/459) .241

Cerebral laceration 6% (35/626) 0% (0/10) 10% (3/30) 9% (2/23) 4% (4/104) 6% (26/459) .605Cerebral contusion 2% (12/626) 0% (0/10) 0% (0/30) 0% (0/23) 1% (1/104) 2% (11/459) .681Other CNS injuries 12% (76/626) 40% (4/10) 27% (8/30) 9% (2/23) 10% (10/104) 11% (52/459) .006Thoracic injuryLung 46% (290/626) 50% (5/10) 50% (15/30) 57% (13/23) 50% (52/104) 45% (205/459) .689Hemothorax/pneumothorax

37% (231/626) 30% (3/10) 30% (9/30) 43% (10/23) 33% (34/104) 38% (175/459) .675

Rib fractures 26% (163/626) 30% (3/10) 27% (8/30) 35% (8/23) 21% (22/104) 27% (122/459) .670Blood vessels a 9% (59/626) 10% (1/10) 20% (6/30) 0% (0/23) 8% (8/104) 10% (44/459) .152Diaphragm 8% (47/626) 20% (2/10) 10% (3/30) 13% (3/23) 4% (4/104) 8% (35/459) .236Other chest injuries 16% (102/626) 40% (4/10) 20% (6/30) 17% (4/23) 8% (8/104) 17% (80/459) .033Intra-abdominal injuryLiver 23% (141/626) 30% (3/10) 30% (9/30) 22% (5/23) 19% (20/104) 23% (104/459) .747Spleen 15% (91/626) 30% (3/10) 10% (3/30) 30% (7/23) 13% (14/104) 14% (64/459) .120Kidney 10% (63/626) 0% (0/10) 13% (4/30) 22% (5/23) 12% (12/104) 9% (42/459) .230Other abdominalorgans

9% (55/626) 20% (2/10) 10% (3/30) 17% (4/23) 7% (7/104) 8% (39/459) .361

P values were derived from χ2 analysis and indicate the probability that the observed distributions could be because of chance. CNS indicates centralnervous system.

a Includes thoracic vessels: thoracic aorta, innominate and subclavian arteries or veins, superior vena cava, pulmonary vessels (artery or vein), intercostalartery or vein, internal mammary artery or vein, azygos vein, and hemiazygos vein.


craniotomy/craniectomy (11 [100%]). Penetrating injury wassustained by 40 (68%) of those who were subjected tothoracotomy and by 1 patient who underwent sternotomy.

Mortality rates among patients were compared accordingto cause of cardiac injury. Patients sustaining a firearm injurywere significantly more likely to die (76%) than those whowere injured in a motor vehicle collision (31%), auto vspedestrian accident (27%), or a fall (25%; P b .001) (Table 2).The most common cause of injury, though, was a motorvehicle crash, in which 47% of patients were involved,followed by a firearm injury, sustained by 22%.

Overall, 484 pediatric patients (77%) sustained associatedinjuries; and 142 (23%) experienced an isolated cardiactrauma. The most common associated injuries were thoracic:46% of the population experienced lung contusions, 37%sustained hemothorax or pneumothorax, and 26% had ribfractures (Table 3A).

No difference in the total incidence of associated injuriesin patients with blunt vs penetrating trauma was noted (77%vs 79%; P = .551). However, patients sustaining blunt cardiac

trauma had a significantly higher incidence of associated head(43% vs 4%; P b .001), lung (50% vs 40%; P = .029), rib(31% vs 17%; P b .001), spleen (20% vs 4%; P b .001), andkidney (13% vs 5%; P = .003) injuries. Conversely, patientswho had penetrating cardiac trauma were significantly morelikely to have associated hemothorax/pneumothorax (45%vs 33%; P = .004), injury to intrathoracic blood vessels(17% vs 5%; P b .001), and diaphragmatic injury (17%vs 3%; P b .001). The incidence of liver injury did notdiffer with injury mechanism (Table 3B).

In 80 patients (13%), a sequela was noted after cardiacinjury, the most common being cardiac arrest in 4% ofthe population. Although only 0.8% of the population hadurinary tract infection (UTI), this complication is the onlyone in which its occurrence differs among the agegroups, affecting significantly more infants than others(10%; P = .009) (Table 4).

The crude mortality rate in the pediatric population was40% (Table 5). Unadjusted mortality was significantlydifferent between age groups, affecting more infants and

Table 3B Associated injuries based on the mechanism of injury

Total a (n = 626) Blunt (n = 402) Penetrating (n = 214) P

Head injurySubarachnoid hemorrhage 13% (81/626) 19% (77/402) 0.9% (2/214) b.001Skull fracture 12% (74/626) 17% (69/402) 2% (4/214) b.001Subdural hemorrhage 12% (72/626) 17% (68/402) 1% (3/214) b.001Epidural hemorrhage 7% (42/626) 10% (39/402) 0.9% (2/214) b.001Cerebral laceration 6% (35/626) 8% (32/402) 0.9% (2/214) b.001Cerebral contusion 2% (12/626) 3% (12/402) 0.0% (0/214) .025Other CNS injuries 12% (76/626) 18% (71/402) 2% (4/214) b.001Thoracic injuryLung 46% (290/626) 50% (200/402) 40% (86/214) .029Hemothorax/pneumothorax 37% (231/626) 33% (133/402) 45% (96/214) .005Rib fractures 26% (163/626) 31% (125/402) 17% (36/214) b.001Blood vessels b 9% (59/626) 5% (22/402) 17% (36/214) b.001Diaphragm 8% (47/626) 3% (11/402) 17% (36/214) b.001Intra-abdominal injuryLiver 23% (141/626) 24% (97/402) 20% (42/214) .241Spleen 15% (91/626) 20% (80/402) 4% (8/214) b.001Kidney 10% (63/626) 13% (51/402) 5% (10/214) .003Other abdominal organs 9% (55/626) 10% (42/402) 6% (12/214) .061

P values were derived from χ2 analysis, with Yates correction, and indicate the probability that the observed distributions could be because of chance.a Total includes blunt, penetrating, and also burn injuries.b Includes thoracic vessels: thoracic aorta, innominate and subclavian arteries or veins, superior vena cava, pulmonary vessels (artery or vein), intercostal

artery or vein, internal mammary artery or vein, azygos vein, and hemiazygos vein.


toddlers than others (50%; P = .027). After adjusting forpossible confounders, the mortality difference lost signifi-cance between the age groups (Table 6). Hospital length ofstay and ICU-LOS did not differ significantly between agegroups (Table 5).

Table 7 lists discharge disposition of the 376 survivors;73%were discharged home after hospitalization, 14% neededrehabilitation, and 7% were transferred to an outside facility.

Table 4 Complications by age group

Total(n = 626)

Infant (b1 y)(n = 10)

Toddler (1-(n = 30)

Cardiac arrest 4% (27/626) 0% (0/10) 3% (1/30)Pneumonia 4% (23/626) 10% (1/10) 0% (0/30)Acute respiratorydistress syndrome

3% (18/626) 0% (0/10) 7% (2/30)

Coagulopathy 2% (11/626) 0% (0/10) 0% (0/30)Wound infection 1% (7/626) 0% (0/10) 0% (0/30)Hypothermia 1% (7/626) 0% (0/10) 0% (0/30)UTI 0.8% (5/626) 10% (1/10) 0% (0/30)Acute renal failure 0.8% (5/626) 0% (0/10) 0% (0/30)Bacteremia 0.5% (3/626) 0% (0/10) 0% (0/30)Deep venous thrombosis(lower extremity)

0.5% (3/626) 0% (0/10) 0% (0/30)

Intra-abdominal abscess 0.5% (3/626) 0% (0/10) 0% (0/30)Empyema 0.5% (3/626) 0% (0/10) 0% (0/30)Pulmonary embolus 0.3% (2/626) 0% (0/10) 0% (0/30)Aspiration pneumonia 0.3% (2/626) 0% (0/10) 0% (0/30)

P values were derived from χ2 analysis and indicate the probability that the obs

3. Discussion

Based on the results of our study, most pediatric patientswho have cardiac trauma are male (75%), experiencing mostfrequently a blunt injury (65%) in the street setting (48%)owing to motor vehicle collisions or vehicle-pedestrianaccidents. Accordingly, other researchers have previouslysuggested that an increase in ownership of motor vehicles in

3 y) Preschool (4-5 y)(n = 23)

School (6-12 y)(n = 104)


P

0% (0/23) 7% (7/104) 4% (19/459) .5470% (0/23) 4% (4/104) 4% (18/459) .5180% (0/23) 4% (4/104) 3% (12/459) .561

0% (0/23) 3% (3/104) 2% (8/459) .7550% (0/23) 3% (3/104) 0.9% (4/459) .4200% (0/23) 0% (0/104) 2% (7/459) .6310% (0/23) 2% (2/104) 0.4% (2/459) .0090% (0/23) 1% (1/104) 0.9% (4/459) .9660% (0/23) 1% (1/104) 0.4% (2/459) .9350% (0/23) 1% (1/104) 0.4% (2/459) .935

0% (0/23) 1% (1/104) 0.4% (2/459) .9350% (0/23) 0% (0/104) 0.7% (3/459) .8950% (0/23) 1% (1/104) 0.2% (1/459) .7910% (0/23) 0% (0/104) 0.4% (2/459) .948

erved distributions could be because of chance.

Table 5 Age-related outcomes


Toddler (1-3 y)(n = 30)


School (6-12 y)(n = 104)


P

Mortality 40% (246/622) 50% (5/10) 50% (15/30) 22% (5/23) 29% (30/104) 42% (191/455) .027Hospital LOS(mean ± SD)

7.0 ± 10.9 9.2 ± 13.3 9.2 ± 15.7 8.8 ± 13.3 8.6 ± 14.0 6.4 ± 9.5 .251 ⁎

ICU-LOS(mean ± SD)

4.0 ± 8.3 7.4 ± 12.7 5.5 ± 10.3 4.9 ± 7.6 5.9 ± 13.4 3.4 ± 6.5 .071 ⁎

P values were derived from χ2 analysis and ANOVA and indicate the probability that the observed distribution of values could be because of chance.⁎ Derived from ANOVA.


adolescents and less adult supervision may result inincreasing blunt trauma and subsequent blunt cardiac injuryin this age group [11]. Our finding confirms that mostinjuries occur in street settings among the adolescentpopulation. This may be because of adolescents' limiteddriving experience. The finding that cardiac injuries in thedomestic environment affect significantly more toddlers maybe because of inadequate parental supervision in this agegroup. These aforementioned hypotheses cannot be con-firmed by NTDB data, so further prospective studies areneeded to clarify these associations between age group andinjury location and address potential underlying causes ofthese patterns. Because we studied a pediatric population inthe United States, we noted relatively low proportion ofpenetrating injuries in our examination [2]. Other studieshave mirrored our findings that most cardiac injuries occur inmen and are because of motor vehicle collisions involvingeither pedestrians or passengers [3,10,12].

When comparing GCS scores between blunt andpenetrating cases, penetrating injuries are significantlymore severe because average GCS in patients sustainingpenetrating injuries is lower than that of blunt patients andbecause a larger percentage of patients with penetratinginjury has a GCS score of 8 or lower compared with patientswith blunt injury.

Regarding surgical interventions, those patients withblunt trauma were more likely to undergo laparotomy orcraniotomy/craniectomy for associated injuries, whereaspatients with penetrating injury were more likely to undergothoracotomy or sternotomy.

Table 6 Risk of death according to age group

Age (y) Adjusted OR (95% CI) Adjusted P value

b1 1 –1-3 0.71 (0.14-3.51) .6754-5 0.31 (0.03-2.79 ) .2956-12 0.45 (0.17-1.19) .10713-17 1.92 (0.84-4.37) .120

Variables in the equation: sex, injury site, mechanism of injury (blunt,penetrating, or burn), SBP less than 90 mm Hg, cardiac contusion,cardiac laceration, subarachnoid hemorrhage, other central nervoussystem injuries, and UTI. CI indicates confidence interval.

When comparing mortality rates among the patients basedon cause of injury, we noted that the highest mortality rateoccurred among those that had a firearm injury. These injuriesaccount for a majority of penetrating injuries in the studypopulation. Mortality rates for all other causes of injuries—composed ofmotor vehicle crash, auto vs pedestrian, and fall—were approximately equal, possibly because most of these areblunt injuries. Mortality rate owing to gunshot injuries wasmuch higher than that of other penetrating nongunshot injuries,which was higher than those of all blunt injuries.

We noted that lesions most commonly associated withpediatric cardiac trauma are lung contusions, hemothorax/pneumothorax, rib fractures, and injuries to the liver. Lunginjury and rib fractures weremore significantly associatedwithblunt cardiac trauma, whereas hemothorax/pneumothorax wasmore significantly associated with penetrating cardiac trauma.We noted liver injuries to be associated with both mechanismsof cardiac insult. Our current findings found rib fractures andpulmonary contusion as the most common associated injuries,followed by head trauma and intra-abdominal injuries. Thisobservation confirms findings of previous studies examiningpediatric cardiac injuries [3,8,10,12].

Blunt cardiac trauma is uncommonly an isolated event inpediatric patients [12]. It has been noted that children areparticularly susceptible to myocardial contusion after bluntchest trauma because of their pliable chest wall [2,9,10].Likewise, pulmonary contusions are found to be associatedwith cardiac contusions in children; yet not all of thesepatients sustain rib fractures [10]. Our current study alsofound that rib fractures in pediatric patients are lesscommon than lung contusions or hemothorax/pneumotho-rax. These findings indicate that pulmonary contusion,especially when accompanied by rib fractures, should beused as an indicator of likely cardiac trauma in the pediatricpopulation. Multiple-system trauma including thoracicinjury should, by default, raise clinical suspicion forpotential cardiac lesion in children.

Overall, our results indicate a low complication rateassociated with pediatric cardiac trauma. The only complica-tion that significantly differed between age groups in our studywas UTI, affecting significantly more infants than others.Although our result is statistically significant, the incidence ofUTI is likely unrelated to cardiac trauma; and our finding is

Table 7 Discharge disposition of survivors


Toddler (1-3 y)(n = 15)


School (6-12 y)(n = 74)

Adolescent (13-17 y)(n = 264)

P

Location .908Home 73% (267/365) 80% (4/5) 67% (10/15) 89% (16/18) 74% (52/70) 72% (185/257)Rehabilitation 14% (51/365) 20% (1/5) 13% (2/15) 0% (0/18) 11% (8/70) 16% (40/257)Hospitaltransfer

7% (25/365) 0% (0/5) 13% (2/15) 6% (1/18) 6% (4/70) 7% (18/257)

Nursing home 0.8% (3/365) 0% (0/5) 0% (0/15) 0% (0/18) 3% (2/70) 0.4% (1/257)Skilled nursingfacility

0.8% (3/365) 0% (0/5) 0% (0/15) 0% (0/18) 0% (0/70) 1% (3/257)

Other 4% (16/365) 0% (0/5) 7% (1/15) 6% (1/18) 6% (4/70) 4% (10/257)

P value was derived from χ2 analysis and indicates the probability that the observed distribution could be because of chance.


likely clinically irrelevant because other authors indicate thatUTI is prevalent in young children in general [13-18].

We observed a high mortality rate of 40% after pediatriccardiac trauma. Other authors have indicated that, aside fromthe severity of injury, delayed diagnosis of pediatrictraumatic cardiac injuries may contribute to such highmortality rates. Blunt cardiac injuries are often overlookedbecause of more visible bodily injuries [9] and whenattention is drawn toward more commonly injured organs[11]. Furthermore, a diagnosis of a cardiac injury may bedelayed for up to several hours or days after admission to ahospital, as noted by Bromberg et al [11].

To the best of our knowledge, this is the first study thatuses the NTDB to comprehensively examine the epidemi-ology of pediatric cardiac trauma and is the study thatanalyzes the largest patient population to date. However, aswith any registry study, reporting bias from the participatingfacilities may have influenced the observed rates of theseinjuries and their associated mortality rates. Moreover, theretrospective nature of this study and that this is a NationalTrauma Data Bank–based analysis precluded examination ofvariables that would have been of great significance, such asserial electrocardiographic findings, determination of creat-inine phosphokinase isoenzymes, troponin levels, echocar-diography, radionuclide angiography studies, structurallocation of cardiac lesions (eg, atrial tears, valvular injuries,and other), operations specified by Current ProceduralTerminology codes, and exact cause of death. Furthermore,the NTDB does not include prehospital deaths, theoccurrence of which is unknown, although probablycommon for cardiac injury patients, so reported mortalitymay underestimate the actual mortality. Well-designedfuture prospective multicenter studies are needed to moreaccurately describe the incidence of cardiac trauma, locationof injury, and outcomes in the pediatric population.

4. Conclusion

In this large pediatric population, the predominantcardiac injury observed was blunt cardiac contusion.

However, 35% of children had sustained penetratingcardiac insults. Pediatric cardiac injury is associated withexcessive overall inhospital mortality at 40%. We observedno age-related difference in adjusted outcomes in thestudied population.

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