Should teens go to pediatric or adult trauma centers?

Adolescents treated at pediatric trauma centers fare better than those treated at adult or mixed facilities, according to a new report, but the researchers stop short of recommending that all adolescents be taken to pediatric facilities for their injuries.

Randall Burd, MD, PhD, chief of trauma and burn surgery at Children’s National Health System in Washington, DC, and one of the authors of the study, says more research is needed to determine if the lower mortality rates of pediatric trauma centers are the result of management practices or differences in the patient population.

“Our study shows that the mortality is lower for injured adolescents treated at pediatric compared to adult trauma centers,” Burd says. “Similar to other diseases treated by both pediatricians and adult providers, this finding raises the possibility that expertise and resources available at pediatric hospitals may have advantages for treating injured patients even as they become young adults.”

The study, published in JAMA Pediatrics, sought to determine whether children treated in pediatric trauma centers fare better than those treated in adult facilities, and found that more adolescents who were treated in adult or mixed trauma centers died when compared with those treated in strictly pediatric centers.

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Trauma is the top cause of death and injury in adolescents, with 39.5% of deaths in individuals aged 10 to 24 years stemming from unintentional injuries, according to the Centers for Disease Control and Prevention. Although younger children in particular require specialized pediatric care, the perceived necessity of pediatric care decreases as children age into adolescence, the researchers say. For this reason, and the fact that resources of pediatric trauma centers are so scarce, adolescents are often taken to adult or mixed trauma centers for treatment. Additionally, there has been little research about the ideal cutoff age for treating adolescents in adult or mixed trauma centers over pediatric centers.

Researchers analyzed data from Level I and Level II trauma centers participating in the 2010 National Trauma Data Bank, and focused on mortality in patients aged 15 to 19 years who were treated for blunt or penetrating injuries.

Of the nearly 30,000 cases reviewed, 68.9% were treated at adult trauma centers; 25.6% were treated at mixed trauma centers; and just 5.5% were treated at pediatric trauma centers.

There were some differences in injury types, with the majority (91.4%) of injuries at pediatric trauma centers being blunt rather than penetrating in nature compared with those treated at adult trauma centers (80.4%) or mixed trauma centers (84.6%).

There was no significant difference in outcomes for adolescents treated in Level I (63.3%) compared with Level II (36.7%) trauma centers, although treatment at Level I trauma centers was more common for those treated in mixed trauma centers (81.9%) compared with pediatric trauma centers (76.1%). Only 55.3% of adolescents treated in adult trauma centers were treated in Level I facilities.

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Patients seen in pediatric trauma centers were on the younger end of their teenaged years and were more likely to be transferred from other facilities. Adolescents treated in adult or mixed trauma centers were mostly 16- and 17-year-olds brought directly from the place of injury, and were more severely injured than those treated at pediatric trauma centers, according to the report.

The most common injuries treated at pediatric trauma centers were falls (25.9% compared with 12.9% at adult trauma centers and 15.1% at mixed trauma centers), or being struck by something (26.1%, compared with 12.3% at adult trauma centers and 13.2% at mixed trauma centers). Motor vehicle accidents, on the other hand, were most frequently treated at adult trauma centers (32.6%), compared with 34.3% at mixed trauma centers and 18.5% at pediatric trauma centers.

Penetrating injuries, such as being shot by a firearm or cut/pierced by an object, were also treated more frequently at adult trauma centers, with 12% of firearm injuries and 7.3% of cut/pierce injuries treated at adult trauma centers compared with 8.3% of firearm injuries and 7.1% of cut/pierce injuries at mixed trauma centers, and 4.5% of firearm and 4.1% of cut/pierce injuries treated at pediatric trauma centers.

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Mortality rates—those adjusted for injury type and those that were not adjusted—were higher for adolescents treated at adult and mixed trauma centers, the study says, ranging from 3.2% at adult trauma centers and 3.5% at mixed trauma centers to 0.4% at pediatric trauma centers.

There are no clear guidelines for when adolescents should be treated in pediatric versus adult facilities, and this study also leaves that question unanswered but offers a call to action for further research.

“To reduce the effect of trauma in this age group, it is essential to determine optimal treatment strategies,” the researchers note. “Because adolescents straddle the gap between pediatric and adult medicine, identifying differences in care among pediatric trauma centers, adult trauma centers, and mixed trauma centers will help determine the most appropriate triage strategies or identify practice strategies that can optimize the outcome for patients in this age group.”

Another recent study in the Journal of Pediatric Surgery asserts that severely injured adolescents fare better at pediatric trauma centers and should therefore be treated there, but Burd says it is premature to recommend that adolescents be treated solely at pediatric trauma centers. Plus, pediatric trauma centers are limited and not capable of taking on all adolescent injuries.

An important next step will be to determine treatment and management differences of adolescent patients in adult and mixed versus pediatric trauma centers, the report states. Although researchers analyzed the results of the study with the varying level of injury type treated in mind, the mortality rates at adult and mixed trauma centers still may have been somewhat skewed by the higher level of acuity in the patients treated there.