Paediatric trauma: injury pattern and mortality in the UK.

OBJECTIVE: Trauma accounts for a large proportion of childhood deaths. No data exist about injury patterns within paediatric trauma in the UK. Identification of specific high-risk injury patterns may lead to improved care and outcome. METHODS: Data from 24 218 paediatric trauma cases recorded by the Trauma Audit and Research Network (TARN) from 1990 to 2005 were analysed. Main injury, injury patterns and outcome were analysed. Mortality at 93 days' post-injury was the major outcome measure. RESULTS: Limb injuries occurred in 65.0% of patients. In infants 81.4% of head injuries were isolated, compared with 46.5% in 11-15-year-old children. Thoracic injuries were associated with other injuries in 68.4%. The overall mortality rate was 3.7% (n = 893). Mortality decreased from 4.2% to 3.1%; this was most evident in non-isolated head injuries. It was low in isolated injuries: 1.5% (n = 293). In children aged 1-15 years the highest mortalities occurred in multiple injuries including head/thoracic (47.7%) and head/abdominal injuries (49.9%). Having a Glasgow Coma Scale of <15 on presentation to hospital was associated with a mortality of 16%. CONCLUSIONS: Differences in injury patterns and mortality exist between different age groups and high-risk injury patterns can be identified. With increasing age, a decline in the proportion of children with head injury and an increase in the proportion with limb injury were observed. This information is useful for directing ongoing care of severely injured children. Future analyses of the TARN database may help to evaluate the management of high-risk children and to identify the most effective care.

Management of limb fractures in children under 1 year of age in a dedicated paediatric emergency department.

BACKGROUND: The recognition of possible non-accidental injury (NAI) in children is an area of ongoing concern for all emergency departments. Limb fractures in non-mobile children should alert clinicians to consider NAI and refer the child for further management. A study was undertaken of the management of such children in a paediatric emergency department (PED) to identify the age and sex of such infants, their mechanism of injury, documentation of developmental milestones, the type of fracture sustained, the number of previous attendances and evidence of referral for senior review and referral to the social services (where appropriate). METHOD: The study was conducted in a large PED which currently sees over 30,000 children per year. A retrospective review was carried out of the notes of all children under 1 year of age presenting with a limb fracture over a 4.5-year period. Patients were identified by their discharge diagnosis on the computerised emergency department (ED) system. RESULTS: 20,497 children under the age of 1 year presented to the ED during the study period. 244 of these presented with limb injuries, of which 39 had fractures. Of these, 36 sets of notes were analysed; 14 of the children were referred for senior review, 10 of whom were thought to be possible NAI and were admitted for further management (median age 23.5 weeks (range 6-48)). This left 22 children under 1 year of age who were seen and managed solely by a PED senior house officer (median age 43 weeks (range 26-51)). In the opinion of the reviewing clinicians, six of these cases may have benefited from senior review. CONCLUSION: Limb fractures in non-mobile children account for a small proportion of PED attendances. There needs to be increased awareness of the potential for NAI in this population. Documentation and understanding of developmental history must be emphasised to show that this has been considered in relation to NAI. Children under 1 year of age are particularly vulnerable and, when they present with a limb fracture, they must be discussed with a senior paediatrician. The changes made locally are discussed and a suggested flow chart provided for possible use in other departments.