The study was conducted at a high volume Level I trauma centre in India. All patients are managed using Advanced Trauma Life Support (ATLS) protocol [3]. Inpatient data from January, 2012 to September, 2017 was collected and de-identified using a unique health identification number, in a prospectively maintained computerized database. Patients aged 18 years or less were included. Age, gender, mechanism of injury, findings of primary and secondary survey, region-wise distribution of injuries, hospital stay and mortality was recorded. The data were entered in a pre-designed performa and analyzed using SPSS version 25. The data were summarized using percentage, median and mean.

There were 906 patients (77% males) with median (IQR) age of 12 (7-17) years. Majority (n=440; 48.6%) belonged to 13-18 y age group, followed by 7-12 y (n=216; 23.8%) and 4-6 y (n=120; 13.2%); toddlers constituted 11.7% of the cohort (n=106). Road traffic injury (RTI) was the commonest cause of trauma (47.4%) (Table I).

Airway was found threatened or compromised in 72 (7.9%) patients. Breathing was compromised in 92 (10.2%). Focused assessment sonography in trauma (FAST) was positive in 294 (32.5%) patients. Glasgow coma scale (GCS) score was subnormal at presentation in 149 (16.4%) patients. Isolated trauma, defined as injury to one abbreviated injury score (AIS) region only was found in 445 (49.1%) patients, whereas 461 (50.9%) had poly-trauma. Median (IQR) Injury Severity Score (ISS) was
9 (4-13).

We had 63 patients with head injury, 14 with neck and 80 patients with maxillo-facial injuries (Web Table I). Two hundred thirteen (23.5%) patients had chest trauma, majority of them (196, 92%) were managed non-operatively; 90 patients required insertion of an ICD tube (Web Table II). Four patients presented with cardiac tamponade, requiring urgent thoracotomy.

There were 370 (40.8%) patients of abdominal trauma, with 351 (94.9%) having blunt trauma while rest had penetrating injuries. Ninety-three percent (188/202) liver and 71.1% (64/90) splenic injuries were success-fully managed non-operatively. We had 78 patients of pelvic injuries, all but one due to blunt trauma; 37 (47.4%) of them required operative intervention for associated abdominal injuries and/or pelvic fixation (Web Table III).

There were nine children with vascular injuries in torso including one internal mammary artery (IMA), one inferior vena cava and one hepatic artery injury. All were repaired except IMA which was ligated. Six patients had pseudoaneurysm of various abdominal vessels that were coil embolized. In extremity vascular trauma, we had 63 arterial and 2 venous injuries in 53 patients. Mode of trauma was sharp in 15 (28.3%) and blunt in rest. All of them underwent various standard surgical procedures (Web Table IV). There was no amputation.

Soft tissue injuries were seen in 132 patients (Web Table V). There were 14 nerve and 15 tendon injuries, all were repaired primarily. There were 157 extremity fractures, 6 dislocations, 11 traumatic amputations, 14 mangled extremities, 33 crush injuries and 9 compart-ment syndromes in 158 patients. One hundred four (65.8%) patients required operative management and rest were managed non-operatively. There were 27 patients with spine injuries; 15 (55.6%) were managed with surgery.

Discharge to home care was possible in 862 patients (95.1%). There were 44 (4.9%) deaths. The commonest cause of mortality was sepsis followed by hemorrhagic shock and head injury (Table I).

Almost half of our patients were less than 12 years of age. It has been reported that the most common pediatric age group affected by injury is 6-12 years [4]. Male to female ratio in our study was 3.36:1, which is in agreement with the published literature [5]. Some investigators have found home to be the most frequent place of injury [6] whereas, similar to our findings, others report RTI as the most common cause [1,5]. Fall from height has been cited as the commonest mechanism of trauma in pediatric age group by various authors [7,8]. We did not find similar result; this could be due to exclusion of neurosurgical patients, as majority of children sustaining fall from height suffer head injuries and are therefore likely to be admitted under care of neurosurgeons.

Most of the children with chest injuries were successfully managed non-operatively with insertion of ICD in select patients. Similar findings have been reported by other authors too [9,10]. This supports that majority of such patients can be managed at centres having basic resources and a team who can care for an injured child. Our experience with traumatic cardiac injuries also reinforced the importance of trauma management protocols in place. We could identify all patients with cardiac tamponade based on mechanism of injury, vital signs and findings of FAST alone. All of them were operated by trauma surgeons without cardio-pulmonary bypass with good results.

We could manage majority of solid visceral injuries with close monitoring alone, as also reported previously [9,10]. This can be accomplished with basic resources like a facility for close observation, blood bank and operation theatre, or a robust referral system to an equipped facility. Similarly, all our patients with extre-mity vascular injury were managed by trauma surgeons with good outcome. Good functional outcome of vascular injuries managed by general surgeons have been reported by others too [11]. Most of the patients with soft tissue injury were managed non-operatively. Early and aggressive treatment of soft tissue injuries in children have been emphasized by other authors as well [12,13].

The mortality rate in our cohort was 4.9%, which is lower than the Western data [14] and that from elsewhere in India [9]. One reason for the low mortality rate in our study may be the exclusion of neurosurgical patients as up to 85% of deaths have been reported due to head injuries in pediatric patients [15]. However, we believe that an organized approach by a committed team with appro-priate resources is able to achieve better outcomes. Better outcome has been reported by many other authors following standard trauma protocols [1].

Limitations of this study include exclusion of patients admitted under neurosurgery and orthopedics; including them could have brought our results closer to actual burden of pediatric trauma in our setting. The single-center data and inclusion of only inpatients also precludes generalization of these findings.

Results comparable to dedicated pediatric trauma centers can be achieved by adopting an organized and protocol-based approach to trauma care. Maintenance of dedicated trauma registries is the need of hour. However, the goal of all studies on pediatric trauma will be fulfilled only when injury prevention strategies are effectively implemented.

Contributors: AR: conceptualized the study, revised the draft critically for important intellectual content, MKJ:acquisition, analysis and interpretation of data for the work, drafted the work and revised it critically for important intellectual content, BM, SK, SS:substantially contributed to the design of the work, revised the manuscript critically for important intellectual content, AG:acquisition and interpretation of data, substantially contributed to the design of the work, revised the manuscript critically for important intellectual content. All authors approved the final version to be published and are accountable for all aspects of the work.

Ethical clearance: Institute Ethics Committee, AIIMS New Delhi; No. IEC-238, dated April 11, 2020.

Funding: None; Competing interest: None stated.

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