Identification of Injured Children at Very Low Risk of Emergent Surgery: a National Trauma Registry Study

Introduction: Accurate triage of trauma patients in need of emergent intervention is essential for optimal outcomes. In recent years, the formation of low risk clinical decision rules has improved patient centered care and resource utilization in diverse medical and surgical populations.

We aimed to derive and internally validate a low-risk rule to identify injured children at very low risk of emergent operative intervention (EOI).

Methods: A retrospective cohort study of the Israeli Trauma Registry of injured children aged 0-14 years between January 2010 and December 2019 admitted to inpatient care.

The primary outcome of the study was EOI, defined as surgery for intracranial, intrathoracic, intra-abdominal within one hour of arrival to the emergency department.

We used multivariate logistic regression to identify candidate predictors for EOI and randomized the patient population to derivation and validation cohorts applying classification tree analyses to generate and validate the low-risk decision rule.

Results: Of 83,859 children included in the analysis, 169 required EOI (0.2%, 95% CI 0.17%- 0.23%). Adjusted Odds Ratio for candidate predictors were: 0.014 (95%CI 0.01-0.019) for Glasgow coma score of 15, 0.276 (95% CI 0.186-0.418) for blunt trauma, 0.477 (95% CI 0.33-0.704) and 0.294 (95% CI 0.176-0.515) for absent age adjusted high risk blood pressure and heart rate respectively. Of 67,816 children, fulfilling all four low risk criteria, 20 underwent EOI (0.029%, 95% CI 0.02%-0.05%).

Conclusion: Our data suggest that a limited set of readily available predictors may enable identification of pediatric trauma patients at an extremely low risk for emergent surgery.