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Direct to operating room trauma resuscitation decreases mortality among severely injured children

Wieck, Minna M., MD; Cunningham, Aaron J., MD; Behrens, Brandon, MD; Ohm, Erika T.; Maxwell, Bryan G., MD, MPH; Hamilton, Nicholas A., MD; Adams, M. Christopher, MD; Cole, Frederick J. Jr., MD; Jafri, Mubeen A., MD

Journal of Trauma and Acute Care Surgery: October 2018 - Volume 85 - Issue 4 - p 659–664
doi: 10.1097/TA.0000000000001908
PTS 2017 PODIUM PAPER
Editor's Choice

BACKGROUND Expediting evaluation and intervention for severely injured patients has remained a mainstay of advanced trauma care. One technique, direct to operating room (DOR) resuscitation, for selective adult patients has demonstrated decreased mortality. We sought to investigate the application of this protocol in children.

METHODS All DOR pediatric patients from 2009 to 2016 at a pediatric Level I trauma center were identified. Direct to OR criteria included penetrating injury, chest injuries, amputations, significant blood loss, cardiopulmonary resuscitation, and surgeon discretion. Demographics, injury patterns, interventions, and outcomes were analyzed. Observed mortality was compared with expected mortality, calculated using Trauma Injury Severity Score methodology, with two-tailed t tests, and a p value less than 0.5 was considered significant.

RESULTS Of 2,956 total pediatric trauma activations, 82 (2.8%) patients (age range, 1 month to 17 years) received DOR resuscitation during the study period. The most common indications for DOR were penetrating injuries (62%) and chest injuries (32%). Forty-four percent had Injury Severity Score (ISS) greater than 15, 33% had Glasgow Coma Scale (GCS) score of 8 or less, and 9% were hypotensive. The most commonly injured body regions were external (66%), head (34%), chest (30%), and abdomen (27%). Sixty-seven (82%) patients required emergent procedural intervention, most commonly wound exploration/repair (35%), central venous access (22%), tube thoracostomy (19%), and laparotomy (18%). Predictors of intervention were ISS greater than 15 (odds ratio, 14; p = 0.013) and GCS < 9 (odds ratio = 8.5, p = 0.044). The survival rate to discharge for DOR patients was 84% compared with an expected survival of 79% (Trauma Injury Severity Score) (p = 0.4). The greatest improvement relative to expected mortality was seen in the subgroup with penetrating trauma (84.5% vs 74.4%; p = 0.002).

CONCLUSION A selective policy of resuscitating the most severely injured children in the OR can decrease mortality. Patients suffering penetrating trauma with the highest ISS, and diminished GCS scores have the greatest benefit. Trauma centers with appropriate resources should evaluate implementing similar policies.

LEVEL OF EVIDENCE Diagnostic tests or criteria, level II.

From the Division of Pediatric Surgery (M.M.W., A.J.C., B.B., N.A.H., M.A.J.), Doernbecher Children’s Hospital, Oregon Health Science University; Department of Pediatric Trauma (E.T.O.), Randall Children’s Hospital; Department of Anesthesiology (B.G.M., M.C.A.), Division of Trauma (F.J.C.J.), Legacy Emanuel Medical Center; and Division of Pediatric Surgery (M.A.J.), Randall Children’s Hospital, Portland, Oregon.

Submitted: November 9, 2017, Revised: February 11, 2018, Accepted: February 16, 2018, Published online: March 19, 2018.

Presented at the Pediatric Trauma Society Annual Meeting, November 4, 2017, Charleston, SC.

Address for reprints: Mubeen Jafri, MD, Division of Pediatric Surgery, Oregon Health Science University, 3181, SW Sam Jackson Park Rd., Mail Code: CDW 7, Portland, OR 97239; email: jafri@ohsu.edu.

Optimizing prehospital and in-hospital triage and treatment during the “golden hour” can reduce the significant morbidity and mortality from traumatic injuries.1–5 To expedite this care, some institutions have implemented a policy of resuscitating the most severely injured patients directly in the operating room (DOR), bypassing the resuscitation suite.6,7 These protocols attempt to predict which patients will require operative intervention and shifts evaluation and care to the operating room (OR) with a goal of expediting management. Based on prehospital triage data, critically injured patients are triaged directly to the OR for evaluation, resuscitation, diagnostics, and any necessary operative intervention. Such a protocol can improve resource and personnel utilization while minimizing unnecessary delays in patient care during a critical period. In adults, implementation of this protocol decreased time to operative intervention,7,8 improved observed survival,7,9 and identified predictors of emergent surgical intervention, namely, penetrating truncal injury, hypotension, and Glasgow Coma Scale (GCS) score less than 9.10

Despite these benefits, this practice has not been evaluated in pediatric trauma patients. Based on protocols for adult trauma patients, our hospital has developed and instituted a DOR policy for treating the most severely injured children. This study aims to describe our experience with a pediatric DOR treatment strategy and to evaluate if this would decrease the expected mortality. We also sought to identify criteria that predict the need for emergent procedural intervention and to assess the cost effectiveness of such a protocol.

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MATERIALS AND METHODS

After obtaining institutional review board approval (IRB 1454), all pediatric patients admitted directly to the OR from 2009 to 2016 were identified from a prospectively maintained trauma registry. All patients were treated at an urban ACS Level 1 Pediatric Trauma Center.

Inclusion criteria for DOR admission are listed in Table 1 and defined in hospital trauma protocols. Exclusion criteria included children who had a lower acuity injury but were evaluated in the OR due to lack of emergency room space.

TABLE 1

TABLE 1

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DOR Trauma Resuscitation

Patients admitted DOR entered through one of two routes: (1) brought directly from the field, usually by emergency medical services or (2) transferred from a lower-level trauma center. The DOR status was decided by the on-call trauma surgeon when receiving patient prenotification. Upon arrival, patients were brought immediately to one of two dedicated trauma ORs by emergency medical services, bypassing any evaluation in the emergency department (ED).

The ORs used for pediatric DOR patients are the same as those used for adult DOR patients. These ORs are equipped with both adult and pediatric sized operative supplies as well as trauma bay resuscitation supplies. They are the main ORs used for all trauma patients, not just DOR patients. The trauma ORs are located directly adjacent to the emergency room trauma bay and computed tomography (CT) scanner. Thus, if a CT scan is warranted once the primary and secondary surveys are completed, patients are taken from the OR on the actual OR table to the scanner, and then returned to the OR. All other imaging and workup is performed directly in the OR in a similar fashion to patients evaluated in the trauma bay. A diagram of the relationship of these rooms has been previously reported.10

The on-call trauma surgeon is available in the hospital at all times. They lead a multidisciplinary trauma team, including a staff anesthesiologist, surgical residents, trauma nurses, respiratory therapists, child life specialists, and radiological technicians. For pediatric DOR admissions, this team is augmented with the pediatric surgery attending, pediatric surgery fellow, pediatric trauma nurse, and pediatric pharmacist. An OR personnel including an OR scrub technician, circulating nurses, and anesthesia aides further supplement the team.

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Outcomes Measurement

Data on patient demographics, triage and examination findings, injury patterns, interventions, and outcomes were collected from a prospectively maintained trauma database. Triage and examination data included vital signs and physical findings from the field or transferring hospital and initial OR evaluation. Injury patterns, including mechanism, affected body region, Injury Severity Score (ISS), and reason for DOR, entry were evaluated. Interventions were recorded, including any procedures, medications, fluids, or other treatment provided in the field, at a transferring hospital (when applicable), and in our institution. The type of intervention and number of separate interventions required during the entire hospital stay were assessed. Length of stay and billed hospital charges for the hospitalization were also evaluated.

The primary outcome measurement was mortality. Based on the patient’s earliest recorded vitals and ISS, expected mortality was calculated with the Trauma Injury Severity Score (TRISS) methodology.11–15 This was compared with observed mortality to determine the impact of the DOR policy. Secondary outcomes included need for procedural intervention and hospital cost. To compare cost, patients admitted DOR and patients evaluated in the ED first with ISS greater than 15 and TRISS less than 0.8 were identified from the same period. Charges for the entire hospitalization were obtained for both groups of patients.

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Statistical Analysis

Descriptive analysis of the entire cohort was performed to identify trends in injury patterns and interventions. Observed and expected mortality rates were compared using χ2 analysis. To identify factors associated with immediate procedural intervention, univariate analyses were performed using 2 × 2 contingency tables to calculate odds ratios. Hospital costs were compared between DOR patients and TRISS-matched non-DOR patients with two-tailed t tests. All analyses were performed on GraphPad (GraphPad Software Inc., San Diego, CA) with p values less than 0.05 considered significant.

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RESULTS

Eighty-five (2.8%) of 2,956 total pediatric trauma patients were admitted as DOR resuscitations over the 8-year study period. Three were excluded because they were lower acuity trauma patients evaluated in the OR due to temporary lack of ED space, leaving 82 patients for analysis. They ranged in age from 1 month to 17 years. Twenty-four (30%) patients were female and 58 (70%) patients were male. Sixty-two patients (76%) were admitted directly from the field while 20 (24%) were transferred from another trauma center. Upon arrival, 18 (22%) patients were already intubated, 12 in the field and 8 at the transferring center. Nine patients (11%) had traumatic arrest and received prehospital PALS, all of whom were admitted from the field. No procedural interventions were performed at transferring institutions.

Reasons for DOR admission and injury patterns are summarized in Table 1. The most common indication for DOR admission was penetrating injury (62%), followed by chest injury (32%). Patients admitted because of physician discretion were most commonly patients with significant closed head injuries with abnormal GCS (9 patients, 11%). Other reasons included unstable extremity fractures (1 patient), severe burns (1 patient), and de-gloving injuries (1 patient).

TABLE 2

TABLE 2

Almost half of the patients (55%) were missing some field vital signs, but data obtained on admission reflects how severely patients were injured (Table 2). Of the patients with vital signs recorded in the field, 17/47 (36%) were tachycardic, 5/57 (8%) were hypotensive, and 15/56 (27%) had Glasgow Coma Scale (GCS) ≤ 8. Complete vital signs from initial evaluation in the OR were recorded for all patients. Twenty-nine patients (36%) were tachycardic, 7/82 (9%) were hypotensive, and 27/82 (33%) had a GCS ≤ 8. Of the hypotensive patients, two had a blunt injury and arrested in the field, resulting in DOR admission. The other five suffered penetrating injuries, leading to DOR admission.

Data regarding the mechanism of injury is summarized in Table 3. A greater number of patients (59%) had a penetrating injury compared to blunt injury (40%). One patient had severe burns. Anatomically, injuries were widely distributed across body regions. The most common injuries were external (66%) or to the head (34%). Almost half of patients (44%) had injuries to multiple body regions. ISS scores ranged from 1 to 50 and 36 patients (44%) had an ISS > 15.

TABLE 3

TABLE 3

The majority of patients (82%) admitted DOR required some emergent procedural intervention (Table 4). The most commonly performed procedure was wound exploration or repair (35%). Major interventions were performed on 44 (54%) patients including laparotomy, thoracotomy, craniotomy, neck exploration or major vascular repair. Furthermore, seven (9%) patients required procedures in multiple body regions. Endotracheal intubation was performed in 42 (51%) patients. Transfusion of blood products was required in 17 patients (21%) and CPR was performed in nine (11%) patients. Sixty-seven (82%) patients had a CT done, 36% before the procedure and 12% after the procedure. Among patients with head injuries who required a craniotomy and/or intracranial pressure monitor placement, eleven patients (79%) had a CT done, nine before the procedure and two afterwards. After initial resuscitation and discharge from the OR, 19 (23%) patients required subsequent procedures during the remainder of their hospitalization.

TABLE 4

TABLE 4

On univariate analysis, no single DOR criterion used for triage was an independent predictor of intervention. Nevertheless, all patients with evisceration of abdominal contents, a rigid abdomen, amputation, or significant blood loss required emergent intervention. Of the vital signs, GCS score of 8 or less was a significant predictor of intervention (OR, 8.5, p = 0.04). The mechanism of injury (blunt versus penetrating) was not a significant predictor. Patients with chest (OR, 3.7) and head (OR, 4.4) injuries were more likely to require emergent intervention. An ISS greater than 15 (OR, 14; p = 0.01) was also a significant predictor of need for intervention.

Sixty-eight (84%) patients survived to discharge. None of the nine patients who arrested in the field survived. The most common injury pattern in nonsurvivors was blunt head trauma; three underwent craniotomy, four had an ICP monitor placed, and 9 of 14 died within the first 24 hours of admission. When compared with predicted mortality as calculated by the TRISS model, DOR patients had a lower mortality (84% observed vs 79% predicted, p = 0.4). This decrease was significant in patients with penetrating trauma (84% observed vs 74% predicted, p = 0.002) (Fig. 1).

Figure 1

Figure 1

To assess the cost effectiveness of this DOR policy, the total hospital charges for the most severely injured (ISS > 15 and TRISS < 0.8) DOR patients were compared with TRISS and ISS matched patients who were evaluated in the ED during this same period. There was no significant difference between total hospitalization costs between the two groups (Table 5). Subgroup analysis of cost was performed to account for difference in survival among groups. This demonstrated no significant difference in hospital charges among patient who survived or died. Additionally, using LOS less than 1 day to remove the confounding impact of long hospital stays on cost, we again found no difference between groups.

TABLE 5

TABLE 5

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DISCUSSION

For the most severely injured children, a selective policy of resuscitation in the OR can decrease mortality, particularly for those with penetrating trauma. Patients with the highest ISS and diminished GCS are the most likely to require operative intervention. Direct to operating room resuscitation facilitated their operative treatment without using trauma bay resources or unnecessary transfer time. Furthermore, instituting a DOR resuscitation protocol for these patients was not more expensive than the standard trauma bay resuscitation protocol.

Implementation of the DOR protocol resulted in lower mortality rates of 16% when compared with expected mortality of 21% based on TRISS scores, reaching statistical significance for patients with penetrating trauma. In comparison, previously reported DOR resuscitation for adults evaluated with the same criteria and resources resulted in a significant decrease in overall mortality from 10% to 5%, but not for the blunt or penetrating injury subpopulations.10 Several factors may account for these differences. First, most of the deaths in our pediatric population were due to blunt head trauma. For this population, prehospital medical management and protocolized traumatic brain injury protocols may have more impact than expediency of operative intervention (with the exception of decompression of space-occupying lesions). Second, in the adult analysis, patients who were declared “dead on arrival” were excluded, which would have increased both observed and expected mortality. None of our pediatric patients were declared “dead on arrival,” even those who arrived with GCS score, 3; SBP, 0; and receiving CPR. It is our policy not to terminate resuscitation until full primary and secondary surveys are completed and further PALS protocols have been deemed futile. Because we are treating these patients, we included them in the analysis, but the inclusion of these patients in our analysis accounts for the higher observed and expected mortality rates of 16% and 21%, respectively.

Third, TRISS may underestimate the risk of death in children because obtaining accurate vital signs and examinations can be difficult.15–17 Values are calculated based on ISS, SBP, respiratory rate, and GCS. Like the adult population, our pediatric population had a similar proportion of patients with an ISS greater than 15 and GCS score of 8 or less. While 16% of adults were hypotensive, only 8% of children were hypotensive, possibly because children respond to hypovolemia primarily with tachycardia and develop hypotension as a late and ominous finding. Over one third of the pediatric patients were tachycardic, and this is a more accurate reflection of their physiologic state, though heart rate is not incorporated into the TRISS calculus. Thus, if a child was hypovolemic enough to elicit tachycardia but not hypotension, the resultant TRISS score may have overestimated the expected survival.

The study may also be underpowered for the absolute reduction in mortality of 5% to reach significance as it did in the adult study. The DOR resuscitation is specifically designed for treatment of the most severely injured patient, but these patients are much rarer in the pediatric population. Over 10 years, 1,407 adults were admitted DOR out of 27,930 total trauma admissions (5%) while in 8 years, only 82 pediatric patients were admitted DOR of almost 3,000 trauma admissions (2.8%). Despite this limited exposure to such severely injured children, treating both the adult and pediatric DOR patients with the same protocol and resources increases the OR staff’s exposure and comfort with performing resuscitation in the operating theatre. It also improves and maintains the entire trauma team’s ability to function in an environment different than the typical trauma bay.

Although DOR patients represented only a small percentage of all pediatric trauma patients, the high proportion of patients with hypotension, tachycardia, GCS score of 8 or less, or ISS greater than 15 among DOR patients reflects how severely injured they were. Most of these patients subsequently required emergent procedural interventions. Although some of these procedures could be performed in the trauma bay, the OR provides a unique advantage of accommodating multiple teams more easily in a more controlled and organized environment. In the OR, advanced resources (dedicated surgical technology and equipment) and the assistance of additional medical personnel (OR nursing, anesthesia technicians, etc.) are also immediately available. Given that almost half of patients had injuries in multiple body regions, the ability to have multiple teams simultaneously evaluate and treat these different areas can facilitate efficient care. Additionally, the ability to move seamlessly between the OR and CT scanner multiple times on the OR bed can allow reassessment of injury or interventions as clinical status changes. The wide spread use of cross-sectional imaging among the study group (82%) and especially among patients with head trauma demonstrated that patients triaged to the OR did not receive care different from the trauma bay. The ability to return to the CT scanner immediately after a procedure (e.g., head CT to ensure lesions are completely drained or decompressed) and back to the OR if necessary provides a unique advantage.

Notably, none of the DOR admission criteria were individually significant predictors of the need for emergent surgical intervention. Although all patients with evisceration of abdominal contents, a rigid abdomen, amputation, or significant blood loss required emergent intervention, the small number of patients admitted under each criterion was underpowered to show a significant predictive association. On the other hand, GCS score of 8 or less was a significant predictor, but it is not a current DOR admission criterion. It has not been added to the DOR criteria because many patients with isolated head injuries do not have space-occupying lesions requiring immediate operative decompression and are better served with early intensive care and medical management. The placement of ICP monitors is easily accomplished in the trauma bay or PICU and generally does not require OR resources.

The DOR resuscitation is a resource intensive policy, which may limit its applicability in other institutions. Compared with the usual protocol of ED resuscitation and subsequent OR transfer if needed, DOR resuscitation requires that additional personnel be in house at all times, including an anesthesiologist, OR scrub nurse, and circulating nurse. An empty OR must always be available for DOR resuscitations, which is a costly institutional investment.18 By bypassing the ED, however, DOR resuscitation has the benefit of freeing up valuable ED rooms and the associated ED personnel required for ED trauma resuscitations, which are duplications of resources when children ultimately require OR intervention. We discovered two patients during the study period who were triaged to the OR (though excluded from analysis) when all available trauma bays were occupied. Overall, we were not able to detect any additional costs for DOR resuscitation compared with the standard ED resuscitation.

Given the resource intense nature of the DOR protocol, further refinement of DOR criteria based on the data presented here could help use resources more appropriately. For example, of the nine patients who arrested in the field, six underwent procedures in the OR suite, but none survived. Given that the outcomes for children who suffered a traumatic arrest remained poor despite immediate operative intervention, perhaps traumatic arrest should be a reason for DOR exclusion rather than inclusion. Conversely, all the patients who were admitted with evisceration of abdominal contents, a rigid abdomen, or a traumatic amputation both underwent procedures and survived. This strongly argues for preserving these indications.

There are additional limitations to this study. Ideally, randomizing patients of comparable severity from the same period to the OR versus trauma bay would be a better comparison of survival between these modalities. We could not justify this since evidence from adult DOR patients clearly demonstrated the benefit of this form of triage. Alternatively, historical controls could have been evaluated for comparison, but we do not have a large enough population to use historical controls without extending the study period so far into the past as to introduce error from the improvement in trauma care over time and poor record keeping before transition to an electronic medical record. Finally, this study includes patients with a wide range of injuries, physiologic responses, and interventions, thus providing several confounding variables.

It is clear from these data that implementing a selective policy of resuscitation of injured children in the OR can improve mortality. This policy is most beneficial for those with penetrating trauma and should be evaluated by pediatric trauma centers with an appropriate layout and available resources.

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AUTHORSHIP

M.M.W. and M.A.J. participated in the study design. M.M.W., A.J.C., B.B., and E.T.O. participated in the data acquisition. M.M.W., A.J.C., and M.A.J. participated in data analysis. M.M.W., A.J.C., and M.A.J. participated in data interpretation. M.M.W. and M.A.J. participated in the drafting of the article. M.M.W., A.J.C., B.B., E.T.O., B.G.M., N.A.H., M.C.A., F.J.C., and M.A.J. participated in the revision of the article.

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DISCLOSURE

None of the authors have any conflicts of interest to disclose.

No funding by the NIH, Wellcome Trust, or Howard Hughes Medical Institute was received.

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Keywords:

Trauma; resuscitation; pediatric; mortality; direct to OR

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