www.elsevier.com/locate/jpedsurg
Key words:
Pediatric cardiac injury;
Age-related outcomes;
Morbidity;
Mortality
Abstract
Background: Few studies of pediatric cardiac injuries have been conducted in large cohorts. We,
therefore, investigated the epidemiology of these injuries in the United States.
Methods: We identified patients with traumatic cardiac injury from the National Trauma Data Bank,
using the International Classification of Diseases, Ninth Revision, codes. Demographic data, clinical
data, and inhospital outcomes were compared among 5 age groups. A logistic regression model was
used to determine adjusted mortality among these groups.
Results: Six hundred twenty-six patients met criteria. Fifty-nine percent sustained cardiac contusion;
36%, laceration. Penetrating injuries proved more severe than blunt, having lower average Glasgow
Coma Scale (6.8 vs 8.7) and higher percentage of patients with Glasgow Coma Scale of 8 or lower (68%
vs 53%). Associated injuries occurred in 484 (77%), most common being lung injuries (46%),
hemopneumothorax (37%), and rib fractures (26%). Eleven percent underwent laparotomy; 9%,
thoracotomy; 2%, craniotomy/craniectomy; and 0.2%, sternotomy. Complications occurred in 80 (13%),
most common being cardiac arrest (4%). Firearm injuries result in the highest mortality rate (76%),
compared with other mechanisms (26%-31%). Crude mortality in different age strata showed significant
differences that were lost after adjustment for confounding variables.
Conclusions: The predominant cardiac injury was blunt (65%; 35% sustained penetrating insults),
frequently paired with contusion. Pediatric cardiac injury is associated with excessive inhospital
mortality (40%), with no age-related difference in adjusted mortality.
2011 Elsevier Inc. All rights reserved.
1565
Male
Race
White
Black
Hispanic
Asian/Pacific Islanders
Native American
Other
Injury site
Street
Home
Public place
Unknown
Other
Mechanism of injury
Blunt
Penetrating
Burn
SBP b90 mm Hg
GCS 8
ISS (mean SD)
15-25
N25
Cardiac injury
Contusion
Laceration
Unspecified/other
Major surgical interventions
Exploratory laparotomy
Resuscitative thoracotomy
Craniotomy/craniectomy
Sternotomy
Preschool
(4-5 y)
(n = 23)
48% (282/586)
24% (142/586)
18% (105/586)
2% (10/586)
0.9% (5/586)
7% (42/586)
60% (6/10)
10% (1/10)
20% (2/10)
0% (0/10)
0% (0/10)
10% (1/10)
43%
17%
23%
3%
3%
10%
(13/30)
(5/30)
(7/30)
(1/30)
(1/30)
(3/30)
32%
27%
14%
0%
5%
23%
(7/22)
(6/22)
(3/22)
(0/22)
(1/22)
(5/22)
46%
30%
12%
3%
1%
9%
(43/94)
(28/94)
(11/94)
(3/94)
(1/94)
(8/94)
48% (299/626)
10% (62/626)
6% (36/626)
23% (141/626)
14% (88/626)
30% (3/10)
30% (3/10)
0% (0/10)
20% (2/10)
20% (2/10)
27%
47%
3%
13%
10%
(8/30)
(14/30)
(1/30)
(4/30)
(3/30)
30%
13%
4%
35%
17%
(7/23)
(3/23)
(1/23)
(8/23)
(4/23)
45%
12%
10%
20%
13%
(47/104)
(12/104)
(10/104)
(21/104)
(14/104)
65% (402/619)
35% (214/619)
0.5% (3/619)
12% (51/419)
59% (325/555)
33.8 21.2
26% (164/626)
57% (355/626)
78% (7/9)
22% (2/9)
0% (0/9)
50% (2/4)
67% (6/9)
41.4 19.8
20% (2/10)
80% (8/10)
77% (23/30)
17% (5/30)
7% (2/30)
50% (10/20)
72% (21/29)
34.7 22.4
27% (8/30)
53% (16/30)
78% (18/23)
22% (5/23)
0% (0/23)
12% (2/17)
45% (9/20)
25.7 18.5
39% (9/23)
39% (9/23)
80% (82/102)
20% (20/102)
0% (0/102)
9% (7/74)
49% (44/89)
30.9 20.4
23% (24/104)
54% (56/104)
54% (247/459)
40% (183/459)
8% (36/459)
.001
.016
.497
11% (67/626)
9% (59/626)
2% (11/626)
0.2% (1/626)
17%
3%
3%
0%
12% (54/459)
10% (47/459)
2% (9/459)
0.2% (1/459)
.236
.657
.824
.985
10% (1/10)
10% (1/10)
0% (0/10)
0% (0/10)
(5/30)
(1/30)
(1/30)
(0/30)
9%
4%
0%
0%
(2/23)
(1/23)
(0/23)
(0/23)
5%
9%
1%
0%
(5/104)
(9/104)
(1/104)
(0/104)
P values were derived from 2 analysis and indicate the probability that the observed distributions could be because of chance.
1566
100%
90%
87.3%
Percentage
80%
70%
60%
50%
40%
30%
20%
10.0%
4.7%
10%
0%
Contusion
Laceration
Type of Cardiac Injury
Unspecified
100.0%
86.0%
90.0%
80.0%
Percentage
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
10.3%
5.6%
0.0%
Contusion
Laceration
Type of Cardiac Injury
Unspecified
2. Results
Overall, 626 patients met inclusion criteria, accounting
for 0.03% of all patients in the NTDB. Of these patients, 10
Mechanism of injury
Firearm
Motor vehicle accident
Auto vs pedestrian
Fall
Other/unspecified/unknown
Total
(n = 622)
Mortality
rate
140
291
26
8
157
76%
31%
27%
25%
26%
P
b.001
1567
Head injury
Subarachnoid
hemorrhage
Skull fracture
Subdural
hemorrhage
Epidural
hemorrhage
Cerebral laceration
Cerebral contusion
Other CNS injuries
Thoracic injury
Lung
Hemothorax/
pneumothorax
Rib fractures
Blood vessels a
Diaphragm
Other chest injuries
Intra-abdominal injury
Liver
Spleen
Kidney
Other abdominal
organs
13% (81/626)
40% (4/10)
20% (6/30)
13% (3/23)
16% (17/104)
11% (51/459)
.036
12% (74/626)
12% (72/626)
10% (1/10)
30% (3/10)
13% (4/30)
10% (3/30)
26% (6/23)
13% (3/23)
12% (12/104)
13% (14/104)
11% (51/459)
11% (49/459)
.306
.382
7% (42/626)
10% (1/10)
0% (0/30)
13% (3/23)
10% (10/104)
6% (28/459)
.241
6% (35/626)
2% (12/626)
12% (76/626)
0% (0/10)
0% (0/10)
40% (4/10)
10% (3/30)
0% (0/30)
27% (8/30)
9% (2/23)
0% (0/23)
9% (2/23)
4% (4/104)
1% (1/104)
10% (10/104)
6% (26/459)
2% (11/459)
11% (52/459)
.605
.681
.006
50% (15/30)
30% (9/30)
57% (13/23)
43% (10/23)
50% (52/104)
33% (34/104)
45% (205/459)
38% (175/459)
.689
.675
26%
9%
8%
16%
(163/626)
(59/626)
(47/626)
(102/626)
30% (3/10)
10% (1/10)
20% (2/10)
40% (4/10)
27%
20%
10%
20%
(8/30)
(6/30)
(3/30)
(6/30)
35%
0%
13%
17%
(8/23)
(0/23)
(3/23)
(4/23)
21% (22/104)
8% (8/104)
4% (4/104)
8% (8/104)
27% (122/459)
10% (44/459)
8% (35/459)
17% (80/459)
.670
.152
.236
.033
23%
15%
10%
9%
30%
10%
13%
10%
(9/30)
(3/30)
(4/30)
(3/30)
22%
30%
22%
17%
(5/23)
(7/23)
(5/23)
(4/23)
19% (20/104)
13% (14/104)
12% (12/104)
7% (7/104)
23% (104/459)
14% (64/459)
9% (42/459)
8% (39/459)
.747
.120
.230
.361
P values were derived from 2 analysis and indicate the probability that the observed distributions could be because of chance. CNS indicates central
nervous system.
a
Includes thoracic vessels: thoracic aorta, innominate and subclavian arteries or veins, superior vena cava, pulmonary vessels (artery or vein), intercostal
artery or vein, internal mammary artery or vein, azygos vein, and hemiazygos vein.
1568
Table 3B
Head injury
Subarachnoid hemorrhage
Skull fracture
Subdural hemorrhage
Epidural hemorrhage
Cerebral laceration
Cerebral contusion
Other CNS injuries
Thoracic injury
Lung
Hemothorax/pneumothorax
Rib fractures
Blood vessels b
Diaphragm
Intra-abdominal injury
Liver
Spleen
Kidney
Other abdominal organs
Total a (n = 626)
Blunt (n = 402)
Penetrating (n = 214)
13% (81/626)
12% (74/626)
12% (72/626)
7% (42/626)
6% (35/626)
2% (12/626)
12% (76/626)
19%
17%
17%
10%
8%
3%
18%
(77/402)
(69/402)
(68/402)
(39/402)
(32/402)
(12/402)
(71/402)
0.9%
2%
1%
0.9%
0.9%
0.0%
2%
(2/214)
(4/214)
(3/214)
(2/214)
(2/214)
(0/214)
(4/214)
b.001
b.001
b.001
b.001
b.001
.025
b.001
46% (290/626)
37% (231/626)
26% (163/626)
9% (59/626)
8% (47/626)
50%
33%
31%
5%
3%
(200/402)
(133/402)
(125/402)
(22/402)
(11/402)
40%
45%
17%
17%
17%
(86/214)
(96/214)
(36/214)
(36/214)
(36/214)
.029
.005
b.001
b.001
b.001
23% (141/626)
15% (91/626)
10% (63/626)
9% (55/626)
24%
20%
13%
10%
(97/402)
(80/402)
(51/402)
(42/402)
20%
4%
5%
6%
(42/214)
(8/214)
(10/214)
(12/214)
.241
b.001
.003
.061
P values were derived from 2 analysis, with Yates correction, and indicate the probability that the observed distributions could be because of chance.
a
Total includes blunt, penetrating, and also burn injuries.
b
Includes thoracic vessels: thoracic aorta, innominate and subclavian arteries or veins, superior vena cava, pulmonary vessels (artery or vein), intercostal
artery or vein, internal mammary artery or vein, azygos vein, and hemiazygos vein.
3. Discussion
Based on the results of our study, most pediatric patients
who have cardiac trauma are male (75%), experiencing most
frequently a blunt injury (65%) in the street setting (48%)
owing to motor vehicle collisions or vehicle-pedestrian
accidents. Accordingly, other researchers have previously
suggested that an increase in ownership of motor vehicles in
Cardiac arrest
Pneumonia
Acute respiratory
distress syndrome
Coagulopathy
Wound infection
Hypothermia
UTI
Acute renal failure
Bacteremia
Deep venous thrombosis
(lower extremity)
Intra-abdominal abscess
Empyema
Pulmonary embolus
Aspiration pneumonia
4% (27/626) 0% (0/10)
4% (23/626) 10% (1/10)
3% (18/626) 0% (0/10)
3% (1/30)
0% (0/30)
7% (2/30)
0% (0/23)
0% (0/23)
0% (0/23)
7% (7/104)
4% (4/104)
4% (4/104)
2% (11/626) 0% (0/10)
1% (7/626)
0% (0/10)
1% (7/626)
0% (0/10)
0.8% (5/626) 10% (1/10)
0.8% (5/626)
0% (0/10)
0.5% (3/626)
0% (0/10)
0.5% (3/626)
0% (0/10)
0%
0%
0%
0%
0%
0%
0%
(0/30)
(0/30)
(0/30)
(0/30)
(0/30)
(0/30)
(0/30)
0%
0%
0%
0%
0%
0%
0%
(0/23)
(0/23)
(0/23)
(0/23)
(0/23)
(0/23)
(0/23)
3%
3%
0%
2%
1%
1%
1%
(3/104)
(3/104)
(0/104)
(2/104)
(1/104)
(1/104)
(1/104)
2% (8/459)
0.9% (4/459)
2% (7/459)
0.4% (2/459)
0.9% (4/459)
0.4% (2/459)
0.4% (2/459)
.755
.420
.631
.009
.966
.935
.935
0.5% (3/626)
0.5% (3/626)
0.3% (2/626)
0.3% (2/626)
0%
0%
0%
0%
(0/30)
(0/30)
(0/30)
(0/30)
0%
0%
0%
0%
(0/23)
(0/23)
(0/23)
(0/23)
1%
0%
1%
0%
(1/104)
(0/104)
(1/104)
(0/104)
0.4% (2/459)
0.7% (3/459)
0.2% (1/459)
0.4% (2/459)
.935
.895
.791
.948
0%
0%
0%
0%
(0/10)
(0/10)
(0/10)
(0/10)
P values were derived from 2 analysis and indicate the probability that the observed distributions could be because of chance.
4% (19/459) .547
4% (18/459) .518
3% (12/459) .561
1569
Age-related outcomes
Mortality
Hospital LOS
(mean SD)
ICU-LOS
(mean SD)
Total (n = 626)
Infant (b1 y)
(n = 10)
Toddler (1-3 y)
(n = 30)
Preschool (4-5 y)
(n = 23)
School (6-12 y)
(n = 104)
Adolescent
(13-17 y)
(n = 459)
40% (246/622)
7.0 10.9
50% (5/10)
9.2 13.3
50% (15/30)
9.2 15.7
22% (5/23)
8.8 13.3
29% (30/104)
8.6 14.0
42% (191/455)
6.4 9.5
.027
.251
4.0 8.3
7.4 12.7
5.5 10.3
4.9 7.6
5.9 13.4
3.4 6.5
.071
P values were derived from 2 analysis and ANOVA and indicate the probability that the observed distribution of values could be because of chance.
Derived from ANOVA.
Age (y)
Adjusted P value
b1
1-3
4-5
6-12
13-17
1
0.71 (0.14-3.51)
0.31 (0.03-2.79 )
0.45 (0.17-1.19)
1.92 (0.84-4.37)
.675
.295
.107
.120
1570
Table 7
Location
Home
Rehabilitation
Hospital
transfer
Nursing home
Skilled nursing
facility
Other
.908
73% (267/365) 80% (4/5)
14% (51/365) 20% (1/5)
7% (25/365)
0% (0/5)
0.8% (3/365)
0.8% (3/365)
4% (16/365)
67% (10/15)
13% (2/15)
13% (2/15)
89% (16/18)
0% (0/18)
6% (1/18)
74% (52/70)
11% (8/70)
6% (4/70)
0% (0/5)
0% (0/5)
0% (0/15)
0% (0/15)
0% (0/18)
0% (0/18)
3% (2/70)
0% (0/70)
0% (0/5)
7% (1/15)
6% (1/18)
6% (4/70)
72% (185/257)
16% (40/257)
7% (18/257)
0.4% (1/257)
1% (3/257)
4% (10/257)
P value was derived from analysis and indicates the probability that the observed distribution could be because of chance.
2
4. Conclusion
In this large pediatric population, the predominant
cardiac injury observed was blunt cardiac contusion.
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