Pediatric firearm-related traumatic brain injury in United States trauma centers
Pediatric firearm-related traumatic brain injury in United States trauma centers
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DOI：
10.3171/2019.5.peds19119
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发表时间：
2019-11-01
影响因子：
1.9
通讯作者：
Tarapore, Phiroz E.
中科院分区：
文献类型：
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作者：
Deng, Hansen;Yue, John K.;Tarapore, Phiroz E.
目的儿童火器伤是美国青少年死亡和残疾的主要原因。头部枪伤（GSWH）的流行病学和结果需要系统的表征。在这里，作者分析了儿科GSWH从人口为基础的样本，以确定长期住院，发病率和death.METHODS的预测因素，所有患者年龄小于18岁，诊断与GSWH在国家样本计划（NSP）的国家创伤数据库（NTDB）在2003-2012年有资格列入本研究。关注的变量包括伤害意图、枪支类型、事件地点、年龄、性别、种族、健康保险、地理区域、创伤中心水平、孤立性创伤性脑损伤（TBI）、急诊室低血压、格拉斯哥昏迷量表（GCS）评分和损伤严重程度评分（ISS）。确定了延长住院时间、发病率和死亡率的风险预测因子。报告比值比、平均增加或减少（B）和95%置信区间。结果在2847例GSWHS患儿的加权样本中，平均年龄为14.8 ± 3.3岁，79.2%为男性，59.0%有严重的TBI（GCS评分3-8）。伤害的原因以袭击（63.0%）、手枪作为火器（45.6%）和在居民区（40.6%）最常见。幸存者的平均住院时间为11.6 +/- 14.4天，相对于意外伤害，自杀性伤害导致住院时间更长（B = 5.9天增加，95% CI 3.3-8.6，p < 0.001）。总体死亡率为45.1%，但因自杀意图（死亡率71.5%，p < 0.001）或由猎枪造成的伤害（死亡率56.5%，p < 0.001）更高。较低的GCS评分、较高的ISS评分和急诊室低血压预示预后较差。有私人保险的患者死亡率低于有医疗保险/医疗补助（OR 2.4，95% CI 1.7-3.4，p < 0.001）或政府保险（OR 3.6，95% CI 2.2-5.8，p < 0.001）的患者。与I级中心相比，II级中心的管理与较低的回家几率相关（OR 0.3，95%CI 0.2-0.5，p < 0.001）。结论从2003年至2012年，关于因GSWH导致的儿科TBI住院，其比例保持稳定，意外伤害导致的比例下降，自杀导致的比例增加。总死亡率为45%。低血压、颅脑损伤和整体损伤严重程度以及自杀意图与预后不良相关。在二级创伤中心接受治疗的患者出院回家的几率较低。鉴于一系列的危险因素，使儿童容易GSWH，强调筛查，家长教育和标准化的重症监护管理是必要的，以改善结果。
OBJECTIVE Pediatric firearm injury is a leading cause of death and disability in the youth of the United States. The epidemiology of and outcomes following gunshot wounds to the head (GSWHs) are in need of systematic characterization. Here, the authors analyzed pediatric GSWHs from a population-based sample to identify predictors of prolonged hospitalization, morbidity, and death.METHODS All patients younger than 18 years of age and diagnosed with a GSWH in the National Sample Program (NSP) of the National Trauma Data Bank (NTDB) in 2003-2012 were eligible for inclusion in this study. Variables of interest included injury intent, firearm type, site of incident, age, sex, race, health insurance, geographic region, trauma center level, isolated traumatic brain injury (TBI), hypotension in the emergency department, Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS). Risk predictors for a prolonged hospital stay, morbidity, and mortality were identified. Odds ratios, mean increases or decreases (B), and 95% confidence intervals were reported. Statistical significance was assessed at alpha < 0.001 accounting for multiple comparisons.RESULTS In a weighted sample of 2847 pediatric patients with GSWHs, the mean age was 14.8 +/- 3.3 years, 79.2% were male, and 59.0% had severe TBI (GCS score 3-8). The mechanism of assault (63.0%), the handgun as firearm (45.6%), and an injury incurred in a residential area (40.6%) were most common. The mean hospital length of stay was 11.6 +/- 14.4 days for the survivors, for whom suicide injuries involved longer hospitalizations (B = 5.9-day increase, 95% CI 3.3-8.6, p < 0.001) relative to those for accidental injuries. Mortality was 45.1% overall but was greater with injury due to suicidal intent (mortality 71.5%, p < 0.001) or caused by a shotgun (mortality 56.5%, p < 0.001). Lower GCS scores, higher ISSs, and emergency room hypotension predicted poorer outcomes. Patients with private insurance had lower mortality odds than those with Medicare/Medicaid (OR 2.4, 95% CI 1.7-3.4, p < 0.001) or government insurance (OR 3.6, 95% CI 2.2-5.8, p < 0.001). Management at level II centers, compared to level I, was associated with lower odds of returning home (OR 0.3, 95% CI 0.2-0.5, p < 0.001).CONCLUSIONS From 2003 to 2012, with regard to pediatric TBI hospitalizations due to GSWHs, their proportion remained stable, those caused by accidental injuries decreased, and those attributable to suicide increased. Overall mortality was 45%. Hypotension, cranial and overall injury severity, and suicidal intent were associated with poor prognoses. Patients treated at level II trauma centers had lower odds of being discharged home. Given the spectrum of risk factors that predispose children to GSWHs, emphasis on screening, parental education, and standardization of critical care management is needed to improve outcomes.