Serious pediatric trauma in South Korea: a nationwide study from 2016 to 2020

Article information

Arch Pediatr Crit Care. 2024;2(2):59-68

Publication date (electronic) : 2024 December 27

doi : https://doi.org/10.32990/apcc.2024.00129

Dahyun Kim, Jun Sung Park

Division of Pediatric Emergency, Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Corresponding author: Jun Sung Park Division of Pediatric Emergency, Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea Email: mrpiglet@naver.com

Received 2024 November 20; Revised 2024 December 5; Accepted 2024 December 7.

Abstract

INTRODUCTION

Trauma is a leading cause of mortality and disability in children worldwide [1]. In the United States, trauma accounts for over 45% of all deaths among children aged 1 to 14 years [2]. Additionally, injuries are responsible for approximately 5% of infant deaths [3]. Furthermore, global trends indicate that reductions in mortality from infectious, nutritional, and neonatal disorders have resulted in a relative increase in the significance of injuries in contributing to the global disease burden [4,5]. The ranking of injuries as causes of death has been found to increase consistently with higher socioeconomic status [4].

Due to anatomical and physiological differences, pediatric trauma patients exhibit unique characteristics compared to adults [6]. These differences include a disproportionately large head, an immature skeletal structure, a higher-positioned airway, a flexible chest wall, relatively large abdominal organs, a high metabolic rate, a large body surface area, increased tissue susceptibility to injury, and a higher risk of internal injuries with fewer external signs of trauma. Additionally, children can maintain blood pressure relatively well despite significant blood loss and tend to experience different injury mechanisms, with falls being more common than traffic accidents (TAs). Socioeconomic variations also influence the patterns of pediatric trauma across different regions or countries [7,8]. Several epidemiological studies have analyzed nationwide data on pediatric trauma patients as a preliminary measure for prevention [9-13].

In South Korea, injuries—including intentional injuries, TAs, and violence—are the leading cause of death in the pediatric population [14]. Trauma accounts for over 20% of deaths in children aged 1 to 9, and intentional injuries are responsible for more than 40% of deaths among adolescents aged 10 to 19 [14]. Given that South Korea has the fastest aging population and the lowest total fertility rate, which is below one, it is crucial to reduce mortality among children and adolescents [15]. However, despite the high mortality and significant medical burden associated with pediatric trauma, there are no studies analyzing nationwide data on this issue in South Korea. Therefore, our goal was to assess the status and characteristics of serious pediatric trauma patients using the National Emergency Department Information System (NEDIS). This database was established to evaluate the operational status of the emergency medical system in Korea and includes information on all emergency department (ED) patient arrivals nationwide.

METHODS

This study was approved by the Institutional Review Board of Human Research at Asan Medical Center (IRB No. 2022-1344), and informed consent was waived.

Study Design and Population

We extracted patient data from the NEDIS. To identify "serious" pediatric trauma patients, we utilized the Korean Triage Acuity System (KTAS) [16], which is based on the Canadian triage acuity system [17]. The KTAS classifies the severity of patients in the ED into five levels, with level 1 being the most severe. We defined "serious" patients as those classified at KTAS levels 1 or 2. This approach was chosen instead of directly analyzing pediatric major trauma cases due to the limitations of the NEDIS database, which does not support the extraction of trauma-specific scores such as the Abbreviated Injury Scale (AIS). The inclusion criteria for the dataset, aside from KTAS level, were as follows: age under 20 years, ED visits due to non-disease causes, and data from the years 2016 to 2020, during which KTAS values were systematically transferred to the NEDIS. We excluded patients with non-disease causes who had isolated burns, drowning, electric injuries, sexual abuse, or intoxication, due to the absence of physical force or differing care pathways (Fig. 1).

Fig. 1.

Flowchart of study population selection. ED, emergency department; KTAS, Korean Triage Acuity System; TCA, traumatic cardiac arrest.

The dataset parameters included the following: demographics such as age and sex; injury characteristics including mechanism and intentionality; pre-arrival information such as time from injury to arrival, the type of facility to which the patient was initially transferred, and ambulance use; and clinical course during the ED stay, which covered initial vital signs, critical procedures, injured body parts, mortality, and disposition. Age was categorized into five groups: <1 year, 1–4 years, 5–9 years, 10–14 years, and 15–19 years. The type of facility was divided into regional emergency medical centers (EMCs) and local EMCs, with regional and local trauma centers classified respectively as regional EMCs and local EMCs. Injured body parts were recorded based on the codes from the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) [18]. A maximum of 40 ICD-10 codes could be recorded for each patient throughout their entire ED stay and hospitalization. Mortality was defined as death occurring either in the ED or during the initial hospitalization post-injury. It was not possible to trace patients who were transferred. Critical procedures were identified using the electronic data interchange (EDI) code submitted to the National Health Insurance [19]. The relevant EDI codes encompassed procedures critical for resuscitation, including those related to airway, breathing, and circulation.

RESULTS

Among 23,811 patients who visited the ED for non-disease causes and were classified as KTAS level 1 or 2, a total of 10,680 patients were included in the study. This selection was made after excluding 11,198 patients without trauma and 1,933 patients who were transferred (Fig. 1). The overall mortality during the 5-year study period was 1,141 (10.7%). Of the patients, 860 (8.1%) presented with traumatic cardiac arrest (TCA) upon arrival, and 812 (94.4%) of these patients died. In contrast, among those without TCA on arrival, 329 (3.4%) died.

Most of the patients were male (7,409, 69.4%), and these male patients exhibited a lower mortality rate than their female counterparts, although the difference was not statistically significant (10.3% vs. 11.6%, p=0.052) (Table 1). The youngest patients, those under 1 year, made up the smallest group (803, 7.5%), while the largest group consisted of those aged 15–19 (3,861, 36.2%). The mortality rate was lowest in the youngest group (6.1%) and highest among the 15–19 age group (15.9%), with both differences being statistically significant (p<0.001). Regional EMCs and local EMCs each treated approximately half of the patients, with 5,446 (51%) and 5,234 (49%) patients respectively, and there was no significant difference in mortality rates between the two settings (p=0.353).

Table 1.

Clinical characteristics of the study population

Most patients sustained unintentional injuries (9,454, 88.5%), while intentional injuries (765, 7.2%) and violent assaults (189, 1.8%) comprised the remaining cases. Intentional injuries exhibited the highest mortality rate among the injury types (26.7%, p<0.001). Falls from a height were the predominant mechanism of injury (3,138, 29.4%), but suffocation or hanging presented the highest mortality rate (49.8%). This was followed by falls from a height (16.6%) and in-car TAs (14.1%). Upon initial presentation to the EMC, deceased patients were significantly more likely to show signs of TCA and a stuporous or comatose mentality (both p<0.001), along with lower measurements in blood pressure, heart rate, respiratory rate, body temperature, and oxygen saturation (all p<0.001). During their ED stay, 791 patients (7.4%) died.

Patients with intentional injuries were predominantly female, comprising 38.1% of the male cohort (p<0.001) (Table 2). These injuries were more commonly caused by suffocation or hanging, falls from heights, and lacerations or stab wounds (all p<0.001). Additionally, these patients were more likely to use ambulances (p=0.001) and exhibited higher severity upon admission, as indicated by a KTAS level 1. They also had more frequent TCA upon arrival and higher mortality rates (all p<0.001). Furthermore, these patients often required critical medical interventions, including mechanical ventilation, endotracheal intubation, cardiopulmonary-cerebral resuscitation, continuous renal replacement therapy, defibrillation, therapeutic hypothermia, craniotomy, invasive intracranial pressure monitoring, and chest tube insertion (all p<0.05).

Table 2.

Clinical characteristics according to intentionality among patients aged 10–19

Among the injured body parts, head injuries were the most common, accounting for 5,859 cases (53.6%), followed by injuries to the upper extremities (2,062 cases, 19.3%) and lower extremities (1,876 cases, 17.6%). Excluding patients with TCA, due to incomplete evaluations and underestimation of injuries, chest and pelvis injuries demonstrated the strongest positive associations with mortality, with odds ratios (ORs) of 5.3 and 5.5, respectively (all p<0.001) in the univariate analysis (Table 3). In the multivariate analysis using logistic regression (Table 4), the presence of a stuporous or comatose mentality and TCA upon arrival were most strongly associated with mortality, with ORs of 71.8 and 29, respectively (all p<0.001). Falls from a height and intentional injuries were also significant predictors of mortality, with ORs of 2.0 and 1.9, respectively (p<0.001 and p=0.003). For patients who did not have TCA upon arrival, injuries to the head, chest, and abdomen were linked to increased mortality, with ORs of 1.6, 2.0, and 1.5, respectively (p<0.001, p<0.001, and p=0.033).

Table 3.

The injured body parts of the patients with blunt trauma, excluding suffocation/hanging

Table 4.

Multivariate regression of factors affecting the mortality

DISCUSSION

In South Korea, there are approximately 2,136 pediatric patients who experience serious trauma annually, with around 228 resulting in fatalities. Given that the average population of children and adolescents aged 0–19 during the study period is 9,422,075 [20], the incidence of serious pediatric trauma is 22.7 per 100,000 per year, and the mortality rate is 2.4 per 100,000 per year. Certain injury characteristics, including the mechanism of injury, the affected body part, and whether the injury was intentional, were linked to higher mortality rates. Patients who suffered from suffocation, hanging, falls from height, in-car TAs, head injuries, chest injuries, abdominal injuries, spine injuries, pelvic bone fractures, and intentional injuries had higher mortality rates compared to those who did not have these conditions. Additionally, intentional injuries in adolescents were associated with a greater demand for medical services compared to unintentional injuries. According to a logistic regression model, cardiac rhythm and mental status upon arrival were the most significant predictors of mortality among the clinical characteristics examined. These findings represent the first comprehensive description of serious pediatric trauma in South Korea.

Globally, the mortality rate among children and adolescents from injuries is increasing, while deaths from diseases are declining, underscoring this trend as a significant social issue [21]. In this study, patients with intentional injuries exhibited higher mortality rates and utilized more medical resources compared to other patients, aligning with findings from other studies [22]. South Korea not only has the world's lowest birth rate but also the highest suicide rate among children and adolescents [23]. Therefore, with the fastest aging population worldwide, prioritizing the prevention of intentional injuries in children and adolescents is imperative in South Korea [24]. However, a substantial number of intentional injuries, including suicides, occur as TCA, which corresponds to out-of-hospital mortality [25]. As a result, these deaths may be challenging to prevent through enhancements in emergency care or trauma resuscitation techniques. Thus, proactive prevention through psychiatric and social interventions becomes even more crucial for intentional injuries, although providing appropriate treatment for affected patients remains essential [26].

Besides intentional injury, altered mentality, and mechanisms such as falls from a height and suffocation, high-risk factors also include injuries to specific body parts like the head, chest, and abdomen. In cases of severe brain injury resulting from trauma, the window for effective intervention is critically short. Rapid increases in intracranial pressure and decreased perfusion swiftly impair brain function, leading to a markedly low survival rate [27,28]. Additionally, injuries to vital organs in the chest and abdomen further reduce survival rates due to loss of physiological function and significant hemorrhage [28]. Conversely, injuries to the lower extremities or pelvis, which are located further from the head, chest, and abdomen, are associated with higher survival rates, partially corroborating the findings of this study [28,29]. Therefore, during the initial assessment of patients with severe trauma, identifying whether the primary damage involves the head or the lower extremities can help estimate survival likelihood.

According to the findings of this study, the annual mortality rate from trauma among children and adolescents in South Korea is 2.4 per 100,000, which is significantly lower than the rate of 19.97 per 100,000 observed in the USA [30]. However, the case fatality rate tells a different story: the overall mortality for patients in this study cohort with a KTAS level of 2 or higher was 10.7%, markedly higher than the 3.2%–3.8% mortality rate reported for severe trauma patients in other national cohorts [9,12,13]. While those studies employed trauma-specific scoring systems such as the International Classification of Injury Severity Score (ICISS) or the AIS, our study utilized KTAS, potentially leading to the selection of patients with relatively worse vital signs. Nonetheless, a review of domestic trauma statistics clearly indicates that the treatment outcomes for severe pediatric trauma in South Korea need improvement. This is further underscored by the W score, which compares the predicted mortality rate based on the Trauma and Injury Severity Score (TRISS) to the actual mortality rate, ranging from –4.53 to –7.79, highlighting the urgent need for enhancement in this area [31].

Major pediatric trauma is distinct from other age groups in terms of its mechanisms of injury and treatment strategies. Although its incidence is lower, once it occurs, the fatality rate is significantly higher [6,25,32]. A study reported that pediatric-designated trauma centers (DTCs) demonstrated better treatment outcomes compared to non-pediatric DTCs and non-trauma centers (NTCs) [33]. However, in South Korea, there are no pediatric DTCs, and there is a significant shortage of human resources such as pediatric trauma specialists and pediatric emergency specialists. The situation in the USA is not significantly different, as pediatric trauma centers are extremely rare. Therefore, many severe pediatric trauma patients are transferred to non-pediatric DTCs or pediatric non-trauma centers, with treatment outcomes reported to vary across studies [33,34]. Oyetunji et al. [35] suggested that a practical and optimal approach would be to operate non-pediatric DTCs with pediatric qualifications. In the study by Bevan et al. [36], a model was proposed to clearly define and effectively allocate the roles of DTCs and NTCs to address the shortage of human and material medical resources. Based on this, to improve specialization in the treatment of severe pediatric trauma in South Korea, it is recommended that golden-time NTCs focus on rapid initial management and prepare for timely transfer to DTCs. Meanwhile, DTCs should be operated with appropriate pediatric trauma qualifications.

This study analyzed extracted ICD-10 diagnosis codes and electronic data interchange procedure codes from national health insurance records. This approach may have led to the omission of some actual diagnoses and procedures, an issue that is likely more pronounced in critical cases such as TCA or in patients who died in the ED. A significant limitation of this study is the absence of objective trauma severity scoring systems like AIS, TRISS, or ICISS. Furthermore, patients who were transferred between facilities without documented final treatment outcomes were excluded from the analysis. Although the data for the 944 patients transferred from the ED likely appeared in other centers' records, the 989 patients transferred during hospitalization without passing through the ED were excluded, which could result in the omission of critical patient outcomes. The nature of the blind national data used in this study meant that detailed clinical information about the patients was not accessible, adding another limitation.

Annually, Korea records approximately 2,172 pediatric patients with serious trauma, resulting in 228 fatalities, which corresponds to a mortality rate of 2.4 per 100,000. Intentional injuries are associated with significantly higher mortality rates and require extensive medical services. The initial cardiac rhythm and mental status upon arrival are the most strongly associated with mortality when compared to other clinical characteristics.

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