Pediatric Trauma Surgery in Iraq and Afghanistan: Mortality, Indicators, and Most Common Operating Room Interventions from 2007-2016.

BACKGROUND: The wars in Afghanistan and Iraq produced thousands of pediatric casualties, utilizing substantial military medical resources. We sought to describe characteristics of pediatric casualties that underwent operative intervention in Iraq and Afghanistan.

METHODS: This is a retrospective analysis of pediatric casualties treated by US Forces in the Department of Defense Trauma Registry (DoDTR) with at least one operative intervention during their course. We report descriptive, inferential statistics, and multivariable modeling to assess associations for receiving an operative intervention and survival. We excluded casualties that died on arrival to the emergency department.

RESULTS: During the study period, there were a total of 3439 children in the DoDTR of which 3388 met inclusion criteria. Of those, 2538 (75%) required at least one operative intervention totaling 13,824 (median 4, IQR 2-7, range 1-57). Compared to nonoperative casualties, operative casualties were older, male, and had a higher proportion of explosive and firearm injuries, higher median composite injury severity scores, higher overall blood product administration, and longer intensive care hospitalizations. The most common operative procedures were related to abdominal, musculoskeletal, and neurosurgical trauma, burn management, and head and neck. When adjusting for confounders, older age (unit OR 1.04, 1.02-1.06), receiving a massive transfusion during their initial 24 hours (6.86, 4.43-10.62), explosive injuries (1.43, 1.17-1.81), firearm injuries (1.94, 1.47-2.55), and age-adjusted tachycardia (1.45, 1.20-1.75) were all associated with going to the operating room. Survival to discharge on initial hospitalization was higher in the operative cohort (95% versus 82%, p < 0.001). When adjusting for confounders, operative intervention was associated with improved mortality (OR 7.43, 5.15-10.72).

CONCLUSIONS: Most children treated in US Military/Coalition treatment facilities required at least one operative intervention. Several pre-operative descriptors were associated with casualties' likelihood of operative interventions. Operative management was associated with improved mortality.

LEVEL OF EVIDENCE: Level III, Prognostic/Epidemiological.