Emergency Trauma Anesthesia Care and Outcomes in Pediatric Firearm and Nonfirearm Injuries: 9-Year Experience From a Regional US Level 1 Trauma Center

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BACKGROUND: In the United States, firearm injuries are the leading cause of pediatric injury mortality. There is little information about anesthetic care and perioperative outcomes of children with firearm injuries. This study compares clinical characteristics, anesthesia care, and perioperative survival of pediatric patients with firearm and nonfirearm injuries. METHODS: We conducted a retrospective cohort study of injured patients <18 years admitted to a regional level 1 US pediatric trauma center between 2014 and 2022 who received anesthetic care within 2 hours of hospital arrival. Differences in clinical characteristics, anesthesia care including therapeutic intensity (arterial and central venous cannulation, blood product transfusion, vasopressor use, or hemostatic agent use) and outcomes (length of stay, mortality, and disposition) were examined between firearm and nonfirearm injury groups and by age groups. RESULTS: During the 9-year study period, pediatric firearm injury hospitalizations tripled, and 25.9% (69/266 trauma admissions) patients received emergency firearm injury anesthesia care. Six (8.8%) patients with firearm injuries were under 10 years. Polytrauma occurred in both firearm (7%) and nonfirearm injury (14%) groups. Compared to nonfirearm injuries, patients with firearm injuries were older ( P < .0001), had fewer American Society of Anesthesiologists (ASA) physical status I ( P = .03) and had more injuries with injury severity score (ISS) 16-25 ( P < .01). Abdominal injury ( P < .001) was more common than traumatic brain injury (TBI; P < .0001) across age groups but all children 1 to 4 years had profound (ISS ≥25) TBI. Time to anesthetic care was shorter ( P < .001), arterial cannulation was more common ( P < .02), estimated blood loss ( P < .001) was greater, and massive transfusion ( P < .0001) was more common during firearm injury anesthesia care. Etomidate ( P = .01), midazolam ( P < .01) and tranexamic acid ( P < .01) use were more common and crystalloid resuscitation was larger ( P < .0001) during firearm injury anesthesia care but varied by age group. Lengths of intensive care unit ( P < .01) and hospital ( P < .01) stay were longer in the firearm injury group. Intraoperative mortality was 1% and 2%, and mortality after the first anesthetic was 6% vs 10% in firearm and nonfirearm injury groups, respectively. All children 1 to 4 years were discharged to advanced placement. CONCLUSIONS: Pediatric trauma patients required high intraoperative therapeutic intensity, which was higher during firearm injury anesthesia care. Postoperative firearm injury mortality was high but less than from nonfirearm injury. Firearm injury patterns, anesthesia care and outcomes varied by age group. Operating room team readiness and provision of timely and high intensity anesthetic care are needed to save lives of injured children.

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