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Epidemiological analysis of pediatric patients with thoracoabdominal trauma in emergency department

Objective: The aim of the study was to evaluate the causes of trauma, diagnostic treatment methods and the results in the patients who were admitted to the emergency department with pediatric thoracic and abdominal trauma. Method: In this study, between January 2014 and December 2018, 959 patients under 18 years of age who were admitted to emergency department due to thorax and abdominal trauma were included. Of these, 557 (58.1%) were male, with a mean age of 9.3 years (range, 1-16 years). Demographic characteristics, trauma patterns and mortality results of these patients were evaluated retrospectively. Results: 933 (97.3%) of the cases were blunt and 2 (2.7%) were penetrating traumas. Of the trauma cases, 436 (4.5%) were falls from lower than one meter, 323 (33.7%) were falls from higher than one meter, 174 (18.1%) were in or non vehicle traffic accidents, 26 (2.7%) were penetrating or sharp object injuries. Mortality was most common in men. In addition, mortality was observed in 11 (1.14%) cases with a fall from height and then 4 (0.4%) cases in a non-vehicle traffic accident. Abdominal organ injury was mostly in the liver, but mortality was more frequent in spleen injuries. Thoracal, lumbar and simple rib fractures were detected mostly in falls, and hemo and pneumothorax were detected in non-vehicle traffic accidents. Conclusions: Most of the thoracic and abdominal traumas can be treated by conservative methods. Mortality and morbidity rates can be decreased by determining the multidisciplinary approach of other system injuries and by giving early decision of procedures.


INTRODUCTION
In the trauma child age group; It is the most important cause of morbidity and mortality in developing and undeveloped countries 1 . Anatomical structures and physiology of children are different from adults. Also, their environment and interests vary from age to age. Although the mechanisms and types of accidents in children vary, the most common causes of trauma in children are car accidents, falls, bike accidents, drowning, burns, and child abuse 2 . Traumas that may be so fatal in childhood and which may cause sequelae should be evaluated in terms of causes, age distribution, and treatment algorithms.
The epidemiology of traumas in the region should be well known to establish a viable and life-saving algorithm and determine requirements until the patient is delivered to the hospital. Pediatric patients who were admitted with trauma were followed up and treated by outpatient or inpatient care were examined. Trauma types, injuries, and results are discussed in the light of literature.

MATERIAL AND METHODS
A total of 959 pediatric patients with thoracic and abdominal trauma who were brought to the emergency departments of Sivas Cumhuriyet University Health Services Application and Research Hospital and Sivas Numune Hospital between January 2014 and December 2018, who were followed up or hospitalized, were included in the study.
The study included patients with falls from height, traffic accidents, and sharp object injuries. Gunshot wounds were not included in the study. Patients falling from heights were divided into two groups as falling from heights below 1 meter (-1mF) and falling from heights above 1 meter (+1mD). Traffic accidents were classified into two groups as vehicle traffic accidents and non-vehicle traffic accidents. Organ injuries were determined by imaging methods (ultrasonography, computed tomography, direct radiography). The patients were retrospectively evaluated for age, gender, causes of trauma, pathologies related to trauma, and mortality reasons.
This study was conducted with the approval of the Sivas Cumhuriyet University Clinical Research Ethics Committee.

Statistical Analysis
The data obtained from this study were analyzed using SPSS 20 package program. While investigating variables from a normal distribution, Shapiro Wilk's was used due to the number of units. Descriptive statistics were shown as mean ± standard deviation or median (minimummaximum) for continuous variables, and nominal variables were shown as several cases and percentage (%). Chi-square analysis was applied to examine the relationship between nominal variables among the groups. If the predicted values in the cells of 2X2 tables were not high enough, Fisher's exact test was used, and the Pearson Chi-square test was used with the help of Monte Carlo Simulation to analyze RxC tables. While evaluating the results, 0.05 was used as the level of significance and values below p <0.05 were considered statistically significant.

RESULTS
The mean age of the patients was 9.3 ± 3.1, and the male / female ratio was 1.38. 58.1% (557) of the patients were male, and 48.1% (402) were female patients ( Table 1). The number of male patients was significantly higher (p <0.001). There was no significant difference in trauma types by age. The mean age of the vehicle accident group and the penetrating injuries group was relatively higher (Fig 1).  Significant differences were found in chi-square test according to whether the types of trauma were determined according to the localization of the thoracic injury (right, left, bilateral), according to the sex, according to the types of rib fractures (single, 2-3, flail chest, sternum injury), according to the presence of hemothorax (Hx) and/or pneumothorax (Px), according to the types of organ injury (liver, spleen, other) According to the results of the study, significant differences were found in the chi-square test ( Table 2, Fig. 2).
There was a statistically significant difference in types of injury according to gender. In the vehicle accident group, there were no male patients, whereas the number of female patients was higher in the penetrating injuries group. The bilateral thoracic injury was more frequent in the +1mD group in terms of thoracic injury type and left thoracic injury was more common in the vehicle accident group. The incidence of right hemithorax injuries was higher in the injuries due to nonvehicle traffic accidents. Unilateral (right + left) thoracic injuries were more frequent in +1mD. Lung contusion was most common in the +1mD group.
It was determined that single-rib fracture was the most common pathology in all trauma types. Sternum fracture was less common in vehicle accidents and penetrating injuries groups. Injury causing flail chest was found to be less in the -1mF and penetrating injuries group.
Px was most frequently seen in the vehicle accident group, but in the -1mF group Px was not seen. Hx was the most common in the nonvehicle accident group, but it was not found in the vehicle accident group. Injuries leading to intraabdominal bleeding were more common in the +1mD and non-vehicle accident group.
Liver injuries were significantly higher in the +1mD group, and splenic trauma was more frequent in the non-vehicle accident group. Other organ injuries (intestine, mesentery, pancreas, etc.) were equally distributed according to trauma types.    (Table 3). Not having; thoracic injuries, rib fractures, Px, organ injuries were found to be statistically significant in injuries that did not result in mortality. When the relationship between mortality and trauma types was examined, it was determined that the most common type of trauma that causes mortality was +1mD, and there was no mortality in the -1mF group and it was found to be statistically significant. There was no statistically significant relationship between sex, intra-abdominal hemorrhage, and presence of Hx and mortality.

DISCUSSION
In our country, as well as in the world, trauma, which is the most common cause of mortality and morbidity in the pediatric age group, is one of the most important health problems 1 . Our study included the evaluation of trauma types and trauma-induced pathologies of patients in the pediatric age group brought to the emergency department of two health centers and their relationship to mortality.
The causes of traumas, which can cause fatal and permanent disabilities and the fact that they constitute a wide scale ranging from infancy to adulthood in terms of age, have difficulties in terms of creating an algorithm. Anatomical and physiological differences cause trauma to cause different pathologies in children. Factors such as climate, culture, development, season, time of day, and age are effective in the frequency of trauma of children 3 .
Studies have shown that boys are exposed to more trauma 4-6 . In our study, trauma was more common in boys, and the most common cause of trauma was -1mF (45.5%). In females, the most common cause of trauma was -1mF (45.3%).
One of the most important groups of patients who applied to the emergency department due to trauma is traffic accidents. The rate of traffic accidents has been reported as 46-59% 7,8 . However, in our study, it was found that the rate of children brought by traffic accident was 18.1%.
In this respect, our study does not show any parallelism with current literature data. This situation was evaluated as a result of the high number of patients in -1mF group in our study and the centers where we conducted the study were easily reached and centralized in terms of transportation.
Since thoracic injuries are a reliable predictor of the severity of injury in children, it is essential to carefully assess children with thoracic trauma. If these injuries are not detected and properly approached, the morbidity risk of children becomes 50% or higher 9 . Pulmonary contusion described by Morgagni in 1971 is a common type of injury due to thoracic trauma. Pulmonary contusion is detected in 17-70% of major injuries 10,11 . Contusion was found in 2.3% of our patients. The reason for this difference may be that the patients in the literature have more +1mD and vehicle traffic accident groups, and in our study group, 45.5% of the patients were in the -1mF group. Ribs are less mineralized and more flexible in children than they are in adults, so during thoracic trauma, the ribs usually stretch and do not break 12 . In our study, rib fractures were seen in a total of 31 patients (3.2%) and were found to be lower than some studies in the literature. It is thought that this case is due to the high number of our cases and the number of patients in the -1mF group compared to the studies in the literature 13 . 14 (45.2%) of the patients who had rib fractures were in the +1mD group. Only 1 (5.5%) of 18 trauma patients with mortality had thoracic trauma (flail chest). In the series of thoracic trauma, the mortality rates detected in the hospital are as low as in our series 14 . This may be because many of the thoracic traumas result with death at the place of injury 15 .
Abdominal trauma accounts for 10-15% of children's traumas admitted to hospital 16 . In our study group, the rate of our patient with abdominal trauma was 3.3%, which is not compatible with the literature, and it is thought that this is due to the high frequency of -1mF group. Mortality was observed in two patients with abdominal trauma, and two patients had splenic injuries.
The rate of pediatric inpatients due to falling in pediatric trauma centers constitutes 25-34 of all child traumas and 6 of children who die from trauma. . 17,18 . Of the patients followed up in our series, 79.1% were trauma cases related to fall, and 11 (1.4%) of these patients had mortality. When the relationship between trauma types and mortality was statistically analyzed, mortality was found to be higher in the +1mD group, and mortality was not observed in the -1mF group.

CONCLUSION
Trauma is a frequent occurrence in emergency departments in the pediatric age group, and trauma types are important for mortality. Therefore, when evaluating trauma patients, questioning trauma types is important in predicting the prognosis of the patient. Fast and urgent evaluation is valuable for survival. It is important to keep in mind that possible organ injuries are more common in certain types of trauma.