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Journal of Pediatric Surgery (2011) 46, 15641571

www.elsevier.com/locate/jpedsurg

Epidemiology of pediatric cardiac injuries: a National


Trauma 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 California
Medical Center, Los Angeles, CA, 90033, USA
Received 2 November 2010; revised 9 February 2011; accepted 10 February 2011

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

Abstract
Background: 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, clinical
data, and inhospital outcomes were compared among 5 age groups. A logistic regression model was
used 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 Glasgow
Coma 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 significant
differences 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 inhospital
mortality (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 of


pediatric cardiac trauma in the United States, as recorded in the National
Trauma Data Bank, the largest trauma registry currently available.
Corresponding author. University of Southern California, Keck
School of Medicine, Department of Surgery, Division of Trauma and
Surgical Critical Care, Los Angeles County General Hospital (LAC + USC),
Los Angeles, CA, 90033-4525, USA.
E-mail address: ykaptein@usc.edu (Y.E. Kaptein).
0022-3468/$ see front matter 2011 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpedsurg.2011.02.041

Thoracic trauma may result in a variety of heart injuries,


ranging from clinically insignificant myocardial contusion
to instantly fatal laceration or rupture [1-7]. Multiple
previous studies have investigated cardiac injuries in
children [1,3-6,8]; however, these examinations consist of
case reports [1,9] or are limited by small patient populations
[2,3,8,10-12]. The largest pediatric population studied to
date consists of 184 children including patients suffering

Epidemiology of pediatric cardiac injuries: a NTDB analysis

lesion. To identify these patients, we used the International


Classification of Diseases, Ninth Revision, codes for
cardiac contusions (861.01 and 861.11), lacerations
(861.02, 861.03, 861.12, and 861.13), and unspecified
injuries (861.00 and 861.10). Patients were subsequently
divided into 5 age groups: infants (b1 year), toddlers (1-3
years), preschool age (4-5 years), school age (6-12 years),
and adolescents (13-17 years). These age divisions were
chosen to reflect activity patterns and lifestyle changes seen
in pediatric patients in the United States, which we
predicted might correlate with types of injuries sustained.
Data collected included demographic and injury characteristics (sex, race, site and mechanism of injury, systolic
blood pressure [SBP], and Glasgow Coma Scale [GCS]
score on admission, Abbreviated Injury Scale, Injury
Severity Score [ISS], and surgical procedures performed),
associated injuries (head, thoracic, and intra-abdominal
injuries), and complications.

solely from blunt cardiac injury [12]. Nevertheless, no


contemporary reviews exist pertinent to penetrating cardiac
lesions in pediatric population.

1. Materials and methods


This is a National Trauma Data Bank (NTDB) analysis
based on Dataset version 7.0 containing 1,861,779 medical
records contributed by more than 900 trauma centers in the
United States from 2002 to 2006. All data provided by the
NTDB are maintained by the American College of
Surgeons and subjected to quality screening for consistency
and validity. The use of NTDB data is in strict compliance
with the Health Insurance Portability and Accountability
Act of 1996.
The study population consisted of all patients younger
than 18 years, diagnosed with at least 1 traumatic cardiac
Table 1

1565

Demographic and injury characteristics according to age group


Total
(n = 626)

Male
Race
White
Black
Hispanic
Asian/Pacific Islanders
Native American
Other
Injury site
Street
Home
Public place
Unknown
Other
Mechanism of injury
Blunt
Penetrating
Burn
SBP b90 mm Hg
GCS 8
ISS (mean SD)
15-25
N25
Cardiac injury
Contusion
Laceration
Unspecified/other
Major surgical interventions
Exploratory laparotomy
Resuscitative thoracotomy
Craniotomy/craniectomy
Sternotomy

Infant (b1 y) Toddler


(n = 10)
(1-3 y)
(n = 30)

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

School (6-12 y) Adolescent


(n = 104)
(13-17 y)
(n = 459)

75% (471/626) 80% (8/10)

60% (18/30) 57% (13/23) 60% (62/104)

48% (282/586)
24% (142/586)
18% (105/586)
2% (10/586)
0.9% (5/586)
7% (42/586)

60% (6/10)
10% (1/10)
20% (2/10)
0% (0/10)
0% (0/10)
10% (1/10)

43%
17%
23%
3%
3%
10%

(13/30)
(5/30)
(7/30)
(1/30)
(1/30)
(3/30)

32%
27%
14%
0%
5%
23%

(7/22)
(6/22)
(3/22)
(0/22)
(1/22)
(5/22)

46%
30%
12%
3%
1%
9%

(43/94)
(28/94)
(11/94)
(3/94)
(1/94)
(8/94)

48% (299/626)
10% (62/626)
6% (36/626)
23% (141/626)
14% (88/626)

30% (3/10)
30% (3/10)
0% (0/10)
20% (2/10)
20% (2/10)

27%
47%
3%
13%
10%

(8/30)
(14/30)
(1/30)
(4/30)
(3/30)

30%
13%
4%
35%
17%

(7/23)
(3/23)
(1/23)
(8/23)
(4/23)

45%
12%
10%
20%
13%

(47/104)
(12/104)
(10/104)
(21/104)
(14/104)

65% (402/619)
35% (214/619)
0.5% (3/619)
12% (51/419)
59% (325/555)
33.8 21.2
26% (164/626)
57% (355/626)

78% (7/9)
22% (2/9)
0% (0/9)
50% (2/4)
67% (6/9)
41.4 19.8
20% (2/10)
80% (8/10)

77% (23/30)
17% (5/30)
7% (2/30)
50% (10/20)
72% (21/29)
34.7 22.4
27% (8/30)
53% (16/30)

78% (18/23)
22% (5/23)
0% (0/23)
12% (2/17)
45% (9/20)
25.7 18.5
39% (9/23)
39% (9/23)

80% (82/102)
20% (20/102)
0% (0/102)
9% (7/74)
49% (44/89)
30.9 20.4
23% (24/104)
54% (56/104)

81% (370/459) b.001


.161
50% (213/430)
24% (102/430)
19% (82/430)
1% (6/430)
0.5% (2/430)
6% (25/430)
b.001
51% (234/459)
7% (30/459)
5% (24/459)
23% (106/459)
14% (65/459)
b.001
60% (272/455)
40% (182/455)
0.2% (1/455)
10% (30/304) b.001
60% (245/408) .113
34.6 21.4
26% (121/459) .605
58% (266/459) .208

59% (368/626) 70% (7/10)


36% (226/626) 30% (3/10)
7% (44/626) 10% (1/10)

70% (21/30) 78% (18/23) 72% (75/104)


33% (10/30) 17% (4/23) 25% (26/104)
0% (0/30)
4% (1/23)
6% (6/104)

54% (247/459)
40% (183/459)
8% (36/459)

.001
.016
.497

11% (67/626)
9% (59/626)
2% (11/626)
0.2% (1/626)

17%
3%
3%
0%

12% (54/459)
10% (47/459)
2% (9/459)
0.2% (1/459)

.236
.657
.824
.985

10% (1/10)
10% (1/10)
0% (0/10)
0% (0/10)

(5/30)
(1/30)
(1/30)
(0/30)

9%
4%
0%
0%

(2/23)
(1/23)
(0/23)
(0/23)

5%
9%
1%
0%

(5/104)
(9/104)
(1/104)
(0/104)

P values were derived from 2 analysis and indicate the probability that the observed distributions could be because of chance.

1566

Y.E. Kaptein et al.

Blunt Cardiac Trauma

100%
90%

87.3%

Percentage

80%
70%
60%
50%
40%
30%
20%

10.0%
4.7%

10%
0%
Contusion

Laceration
Type of Cardiac Injury

Unspecified

Penetrating Cardiac Trauma

100.0%
86.0%

90.0%
80.0%

Percentage

70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%

10.3%

5.6%

0.0%
Contusion

Laceration
Type of Cardiac Injury

Unspecified

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


and penetrating trauma (B).

Primary outcome was mortality, and secondary outcomes


included hospital length of stay and intensive care unit length
of stay (ICU-LOS). Contingency tables were created for each
data set, and statistical analysis was performed using 2 with
Yates correction or Fisher exact test for dichotomous
variables and analysis of variance (ANOVA) for continuous
variables. Categorical variables are described as percentages
of each age group falling under each category, with associated
P values. Continuous variables are described as mean SD.
The younger age stratum (b1 year) was set as the reference
population to which the older age groups were compared,
with respect to outcomes. To adjust for confounding factors, a
multivariable logistic regression model was used; and the
adjusted mortality between the remaining 4 age groups was
calculated. Factors significantly different between the 5 age
groups at a P b .05 level were entered into the regression
model. Odds ratio (OR) and 95% confidence interval were
calculated 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 for
Windows, version 12.0 (SPSS Inc, Chicago, IL).

2. Results
Overall, 626 patients met inclusion criteria, accounting
for 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). The
most common setting of injury was the street, where 48% of
total injuries occurred. Adolescents incurred injuries in this
setting (51%) more frequently than did other age groups (P b
.001). The second most common site of injury was a
domestic setting, where 10% of injuries occurred, with
toddlers' 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 being
significantly higher in school-age children (80%; P b .001).
Overall, 12% of the patients were hypotensive (SBP, b90
mm Hg) on admission; and 59% sustained an associated severe
traumatic 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 that
are contusions is significantly higher in preschoolers (78%)
compared with other age groups (P = .001). Cardiac lacerations
occurred in 36%, with adolescents experiencing the greatest
proportion of laceration vs other injuries (40%; P = .016)
(Table 1). Among patients who sustained blunt trauma, most
(87%) had cardiac contusion (Fig. 1A). Conversely, patients
sustaining penetrating trauma were more likely to have heart
laceration (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 sustained
penetrating injury, the average GCS score was 6.8 5.5 (P b
.001). Fifty-three percent (180/342) of blunt injury patients
with known GCS had a GCS score of 8 or lower, whereas
68% (139/203) of penetrating injury patients had a GCS
score of 8 or lower (P b .001).
The most common surgical intervention was exploratory
laparotomy, 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 who
underwent laparotomy and by all patients who underwent
Table 2

Mortality based on the mechanism of injury

Mechanism of injury
Firearm
Motor vehicle accident
Auto vs pedestrian
Fall
Other/unspecified/unknown

Total
(n = 622)

Mortality
rate

140
291
26
8
157

76%
31%
27%
25%
26%

P
b.001

Survival status is unknown for 4 patients (3 involved in motor vehicle


accidents and 1 other). P value was derived from 2 analysis and
indicates the probability that the distribution of survival vs mortality
for mechanisms of injury could be because of chance.

Epidemiology of pediatric cardiac injuries: a NTDB analysis


Table 3A

1567

Associated injuries based on age


Total (n = 626) Infant (b1 y) Toddler (1-3 y) Preschool (4-5 y) School (6-12 y) Adolescent (13-17 y) P
(n = 10)
(n = 30)
(n = 23)
(n = 104)
(n = 459)

Head injury
Subarachnoid
hemorrhage
Skull fracture
Subdural
hemorrhage
Epidural
hemorrhage
Cerebral laceration
Cerebral contusion
Other CNS injuries
Thoracic injury
Lung
Hemothorax/
pneumothorax
Rib fractures
Blood vessels a
Diaphragm
Other chest injuries
Intra-abdominal injury
Liver
Spleen
Kidney
Other abdominal
organs

13% (81/626)

40% (4/10)

20% (6/30)

13% (3/23)

16% (17/104)

11% (51/459)

.036

12% (74/626)
12% (72/626)

10% (1/10)
30% (3/10)

13% (4/30)
10% (3/30)

26% (6/23)
13% (3/23)

12% (12/104)
13% (14/104)

11% (51/459)
11% (49/459)

.306
.382

7% (42/626)

10% (1/10)

0% (0/30)

13% (3/23)

10% (10/104)

6% (28/459)

.241

6% (35/626)
2% (12/626)
12% (76/626)

0% (0/10)
0% (0/10)
40% (4/10)

10% (3/30)
0% (0/30)
27% (8/30)

9% (2/23)
0% (0/23)
9% (2/23)

4% (4/104)
1% (1/104)
10% (10/104)

6% (26/459)
2% (11/459)
11% (52/459)

.605
.681
.006

46% (290/626) 50% (5/10)


37% (231/626) 30% (3/10)

50% (15/30)
30% (9/30)

57% (13/23)
43% (10/23)

50% (52/104)
33% (34/104)

45% (205/459)
38% (175/459)

.689
.675

26%
9%
8%
16%

(163/626)
(59/626)
(47/626)
(102/626)

30% (3/10)
10% (1/10)
20% (2/10)
40% (4/10)

27%
20%
10%
20%

(8/30)
(6/30)
(3/30)
(6/30)

35%
0%
13%
17%

(8/23)
(0/23)
(3/23)
(4/23)

21% (22/104)
8% (8/104)
4% (4/104)
8% (8/104)

27% (122/459)
10% (44/459)
8% (35/459)
17% (80/459)

.670
.152
.236
.033

23%
15%
10%
9%

(141/626) 30% (3/10)


(91/626) 30% (3/10)
(63/626)
0% (0/10)
(55/626) 20% (2/10)

30%
10%
13%
10%

(9/30)
(3/30)
(4/30)
(3/30)

22%
30%
22%
17%

(5/23)
(7/23)
(5/23)
(4/23)

19% (20/104)
13% (14/104)
12% (12/104)
7% (7/104)

23% (104/459)
14% (64/459)
9% (42/459)
8% (39/459)

.747
.120
.230
.361

P values were derived from 2 analysis and indicate the probability that the observed distributions could be because of chance. CNS indicates central
nervous system.
a
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.

craniotomy/craniectomy (11 [100%]). Penetrating injury was


sustained by 40 (68%) of those who were subjected to
thoracotomy and by 1 patient who underwent sternotomy.
Mortality rates among patients were compared according
to cause of cardiac injury. Patients sustaining a firearm injury
were significantly more likely to die (76%) than those who
were injured in a motor vehicle collision (31%), auto vs
pedestrian accident (27%), or a fall (25%; P b .001) (Table 2).
The most common cause of injury, though, was a motor
vehicle crash, in which 47% of patients were involved,
followed by a firearm injury, sustained by 22%.
Overall, 484 pediatric patients (77%) sustained associated
injuries; and 142 (23%) experienced an isolated cardiac
trauma. The most common associated injuries were thoracic:
46% of the population experienced lung contusions, 37%
sustained hemothorax or pneumothorax, and 26% had rib
fractures (Table 3A).
No difference in the total incidence of associated injuries
in 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), and
kidney (13% vs 5%; P = .003) injuries. Conversely, patients
who had penetrating cardiac trauma were significantly more
likely 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 not
differ with injury mechanism (Table 3B).
In 80 patients (13%), a sequela was noted after cardiac
injury, the most common being cardiac arrest in 4% of
the population. Although only 0.8% of the population had
urinary tract infection (UTI), this complication is the only
one in which its occurrence differs among the age
groups, affecting significantly more infants than others
(10%; P = .009) (Table 4).
The crude mortality rate in the pediatric population was
40% (Table 5). Unadjusted mortality was significantly
different between age groups, affecting more infants and

1568
Table 3B

Y.E. Kaptein et al.


Associated injuries based on the mechanism of injury

Head injury
Subarachnoid hemorrhage
Skull fracture
Subdural hemorrhage
Epidural hemorrhage
Cerebral laceration
Cerebral contusion
Other CNS injuries
Thoracic injury
Lung
Hemothorax/pneumothorax
Rib fractures
Blood vessels b
Diaphragm
Intra-abdominal injury
Liver
Spleen
Kidney
Other abdominal organs

Total a (n = 626)

Blunt (n = 402)

Penetrating (n = 214)

13% (81/626)
12% (74/626)
12% (72/626)
7% (42/626)
6% (35/626)
2% (12/626)
12% (76/626)

19%
17%
17%
10%
8%
3%
18%

(77/402)
(69/402)
(68/402)
(39/402)
(32/402)
(12/402)
(71/402)

0.9%
2%
1%
0.9%
0.9%
0.0%
2%

(2/214)
(4/214)
(3/214)
(2/214)
(2/214)
(0/214)
(4/214)

b.001
b.001
b.001
b.001
b.001
.025
b.001

46% (290/626)
37% (231/626)
26% (163/626)
9% (59/626)
8% (47/626)

50%
33%
31%
5%
3%

(200/402)
(133/402)
(125/402)
(22/402)
(11/402)

40%
45%
17%
17%
17%

(86/214)
(96/214)
(36/214)
(36/214)
(36/214)

.029
.005
b.001
b.001
b.001

23% (141/626)
15% (91/626)
10% (63/626)
9% (55/626)

24%
20%
13%
10%

(97/402)
(80/402)
(51/402)
(42/402)

20%
4%
5%
6%

(42/214)
(8/214)
(10/214)
(12/214)

.241
b.001
.003
.061

P values were derived from 2 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 for


possible confounders, the mortality difference lost significance between the age groups (Table 6). Hospital length of
stay and ICU-LOS did not differ significantly between age
groups (Table 5).
Table 7 lists discharge disposition of the 376 survivors;
73% were discharged home after hospitalization, 14% needed
rehabilitation, and 7% were transferred to an outside facility.
Table 4

3. Discussion
Based on the results of our study, most pediatric patients
who have cardiac trauma are male (75%), experiencing most
frequently a blunt injury (65%) in the street setting (48%)
owing to motor vehicle collisions or vehicle-pedestrian
accidents. Accordingly, other researchers have previously
suggested that an increase in ownership of motor vehicles in

Complications by age group


Total
(n = 626)

Cardiac arrest
Pneumonia
Acute respiratory
distress syndrome
Coagulopathy
Wound infection
Hypothermia
UTI
Acute renal failure
Bacteremia
Deep venous thrombosis
(lower extremity)
Intra-abdominal abscess
Empyema
Pulmonary embolus
Aspiration pneumonia

Infant (b1 y) Toddler (1-3 y) Preschool (4-5 y) School (6-12 y) Adolescent


(n = 10)
(n = 30)
(n = 23)
(n = 104)
(13-17 y)
(n = 459)

4% (27/626) 0% (0/10)
4% (23/626) 10% (1/10)
3% (18/626) 0% (0/10)

3% (1/30)
0% (0/30)
7% (2/30)

0% (0/23)
0% (0/23)
0% (0/23)

7% (7/104)
4% (4/104)
4% (4/104)

2% (11/626) 0% (0/10)
1% (7/626)
0% (0/10)
1% (7/626)
0% (0/10)
0.8% (5/626) 10% (1/10)
0.8% (5/626)
0% (0/10)
0.5% (3/626)
0% (0/10)
0.5% (3/626)
0% (0/10)

0%
0%
0%
0%
0%
0%
0%

(0/30)
(0/30)
(0/30)
(0/30)
(0/30)
(0/30)
(0/30)

0%
0%
0%
0%
0%
0%
0%

(0/23)
(0/23)
(0/23)
(0/23)
(0/23)
(0/23)
(0/23)

3%
3%
0%
2%
1%
1%
1%

(3/104)
(3/104)
(0/104)
(2/104)
(1/104)
(1/104)
(1/104)

2% (8/459)
0.9% (4/459)
2% (7/459)
0.4% (2/459)
0.9% (4/459)
0.4% (2/459)
0.4% (2/459)

.755
.420
.631
.009
.966
.935
.935

0.5% (3/626)
0.5% (3/626)
0.3% (2/626)
0.3% (2/626)

0%
0%
0%
0%

(0/30)
(0/30)
(0/30)
(0/30)

0%
0%
0%
0%

(0/23)
(0/23)
(0/23)
(0/23)

1%
0%
1%
0%

(1/104)
(0/104)
(1/104)
(0/104)

0.4% (2/459)
0.7% (3/459)
0.2% (1/459)
0.4% (2/459)

.935
.895
.791
.948

0%
0%
0%
0%

(0/10)
(0/10)
(0/10)
(0/10)

P values were derived from 2 analysis and indicate the probability that the observed distributions could be because of chance.

4% (19/459) .547
4% (18/459) .518
3% (12/459) .561

Epidemiology of pediatric cardiac injuries: a NTDB analysis


Table 5

1569

Age-related outcomes

Mortality
Hospital LOS
(mean SD)
ICU-LOS
(mean SD)

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)

40% (246/622)
7.0 10.9

50% (5/10)
9.2 13.3

50% (15/30)
9.2 15.7

22% (5/23)
8.8 13.3

29% (30/104)
8.6 14.0

42% (191/455)
6.4 9.5

.027
.251

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 2 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 in


increasing blunt trauma and subsequent blunt cardiac injury
in this age group [11]. Our finding confirms that most
injuries occur in street settings among the adolescent
population. This may be because of adolescents' limited
driving experience. The finding that cardiac injuries in the
domestic environment affect significantly more toddlers may
be because of inadequate parental supervision in this age
group. These aforementioned hypotheses cannot be confirmed by NTDB data, so further prospective studies are
needed to clarify these associations between age group and
injury location and address potential underlying causes of
these patterns. Because we studied a pediatric population in
the United States, we noted relatively low proportion of
penetrating injuries in our examination [2]. Other studies
have mirrored our findings that most cardiac injuries occur in
men and are because of motor vehicle collisions involving
either pedestrians or passengers [3,10,12].
When comparing GCS scores between blunt and
penetrating cases, penetrating injuries are significantly
more severe because average GCS in patients sustaining
penetrating injuries is lower than that of blunt patients and
because a larger percentage of patients with penetrating
injury has a GCS score of 8 or lower compared with patients
with blunt injury.
Regarding surgical interventions, those patients with
blunt trauma were more likely to undergo laparotomy or
craniotomy/craniectomy for associated injuries, whereas
patients with penetrating injury were more likely to undergo
thoracotomy or sternotomy.
Table 6

Risk of death according to age group

Age (y)

Adjusted OR (95% CI)

Adjusted P value

b1
1-3
4-5
6-12
13-17

1
0.71 (0.14-3.51)
0.31 (0.03-2.79 )
0.45 (0.17-1.19)
1.92 (0.84-4.37)

.675
.295
.107
.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 nervous
system injuries, and UTI. CI indicates confidence interval.

When comparing mortality rates among the patients based


on cause of injury, we noted that the highest mortality rate
occurred among those that had a firearm injury. These injuries
account for a majority of penetrating injuries in the study
population. Mortality rates for all other causes of injuries
composed of motor vehicle crash, auto vs pedestrian, and fall
were approximately equal, possibly because most of these are
blunt injuries. Mortality rate owing to gunshot injuries was
much higher than that of other penetrating nongunshot injuries,
which was higher than those of all blunt injuries.
We noted that lesions most commonly associated with
pediatric cardiac trauma are lung contusions, hemothorax/
pneumothorax, rib fractures, and injuries to the liver. Lung
injury and rib fractures were more significantly associated with
blunt cardiac trauma, whereas hemothorax/pneumothorax was
more significantly associated with penetrating cardiac trauma.
We noted liver injuries to be associated with both mechanisms
of cardiac insult. Our current findings found rib fractures and
pulmonary contusion as the most common associated injuries,
followed by head trauma and intra-abdominal injuries. This
observation confirms findings of previous studies examining
pediatric cardiac injuries [3,8,10,12].
Blunt cardiac trauma is uncommonly an isolated event in
pediatric patients [12]. It has been noted that children are
particularly susceptible to myocardial contusion after blunt
chest trauma because of their pliable chest wall [2,9,10].
Likewise, pulmonary contusions are found to be associated
with cardiac contusions in children; yet not all of these
patients sustain rib fractures [10]. Our current study also
found that rib fractures in pediatric patients are less
common than lung contusions or hemothorax/pneumothorax. These findings indicate that pulmonary contusion,
especially when accompanied by rib fractures, should be
used as an indicator of likely cardiac trauma in the pediatric
population. Multiple-system trauma including thoracic
injury should, by default, raise clinical suspicion for
potential cardiac lesion in children.
Overall, our results indicate a low complication rate
associated with pediatric cardiac trauma. The only complication that significantly differed between age groups in our study
was UTI, affecting significantly more infants than others.
Although our result is statistically significant, the incidence of
UTI is likely unrelated to cardiac trauma; and our finding is

1570
Table 7

Y.E. Kaptein et al.


Discharge disposition of survivors
Total (n = 376) Infant (b1 y) Toddler (1-3 y) Preschool (4-5 y) School (6-12 y) Adolescent (13-17 y) P
(n = 5)
(n = 15)
(n = 18)
(n = 74)
(n = 264)

Location
Home
Rehabilitation
Hospital
transfer
Nursing home
Skilled nursing
facility
Other

.908
73% (267/365) 80% (4/5)
14% (51/365) 20% (1/5)
7% (25/365)
0% (0/5)
0.8% (3/365)
0.8% (3/365)
4% (16/365)

67% (10/15)
13% (2/15)
13% (2/15)

89% (16/18)
0% (0/18)
6% (1/18)

74% (52/70)
11% (8/70)
6% (4/70)

0% (0/5)
0% (0/5)

0% (0/15)
0% (0/15)

0% (0/18)
0% (0/18)

3% (2/70)
0% (0/70)

0% (0/5)

7% (1/15)

6% (1/18)

6% (4/70)

72% (185/257)
16% (40/257)
7% (18/257)
0.4% (1/257)
1% (3/257)
4% (10/257)

P value was derived from analysis and indicates the probability that the observed distribution could be because of chance.
2

likely clinically irrelevant because other authors indicate that


UTI is prevalent in young children in general [13-18].
We observed a high mortality rate of 40% after pediatric
cardiac trauma. Other authors have indicated that, aside from
the severity of injury, delayed diagnosis of pediatric
traumatic cardiac injuries may contribute to such high
mortality rates. Blunt cardiac injuries are often overlooked
because of more visible bodily injuries [9] and when
attention is drawn toward more commonly injured organs
[11]. Furthermore, a diagnosis of a cardiac injury may be
delayed for up to several hours or days after admission to a
hospital, as noted by Bromberg et al [11].
To the best of our knowledge, this is the first study that
uses the NTDB to comprehensively examine the epidemiology of pediatric cardiac trauma and is the study that
analyzes the largest patient population to date. However, as
with any registry study, reporting bias from the participating
facilities may have influenced the observed rates of these
injuries and their associated mortality rates. Moreover, the
retrospective nature of this study and that this is a National
Trauma Data Bankbased analysis precluded examination of
variables that would have been of great significance, such as
serial electrocardiographic findings, determination of creatinine phosphokinase isoenzymes, troponin levels, echocardiography, radionuclide angiography studies, structural
location of cardiac lesions (eg, atrial tears, valvular injuries,
and other), operations specified by Current Procedural
Terminology codes, and exact cause of death. Furthermore,
the NTDB does not include prehospital deaths, the
occurrence of which is unknown, although probably
common for cardiac injury patients, so reported mortality
may underestimate the actual mortality. Well-designed
future prospective multicenter studies are needed to more
accurately describe the incidence of cardiac trauma, location
of injury, and outcomes in the pediatric population.

4. Conclusion
In this large pediatric population, the predominant
cardiac injury observed was blunt cardiac contusion.

However, 35% of children had sustained penetrating


cardiac insults. Pediatric cardiac injury is associated with
excessive overall inhospital mortality at 40%. We observed
no age-related difference in adjusted outcomes in the
studied population.

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