STROBE Statement—Checklist of items that should be included in reports of cohort studies

Item
No Recommendation
Title and abstract 1 (a) Polytrauma Among Paediatric Patients
(b) The goals of initial trauma management in children, as in adults, are to rapidly
assess injuries, determine management priorities and provide critical interventions.
Achieving these goals requires, a systematic and logical approach per Advanced
Trauma Life Support principles. Material and Methods: The present research is an
analytical study, the databases including information obtained from a total of 89
paediatric subjects, presented to the Emergency Department of the Emergency
Hospital of Galati, as victims of a traumatic event. From there, according to the
inclusion criteria established at the beginning of the process, a final working group of
80 patients was obtained (excluding those with incomplete data). Results: At the batch
level, the predominance of cases registered in the years 2015-2017 (with a total of
62.5% of the total number of patients) is noted. The lowest incidences are detected in
patients enrolled in the study group in the final period of the statistical analysis (2020,
2021). Discussion: The majority of children suffered injuries at home (63.9% of
patients). The cause of injury in the paediatric population was fall from standing
(26.9%patients). Conclusion: Factors predisposing to paediatric trauma have rarely
been investigated and there are currently no injury prevention programs for the
paediatric population. Trauma is the leading cause of morbidity and mortality among
children and adolescents in both developed and developing countries. A
multidisciplinary approach is necessary and imperative, and patients need to be
managed in specialized centers to optimize care and achieve the most effective
functional recovery.
Introduction
Background/rationale 2 In Romania, in the last 5 years, in children and young people (0-19) years, mortality
due to trauma and other external causes is decreasing, with an incidence of 1536.5
percent of inhabitants. In 2020 there were 3266 new cases of road accidents and 380
injuries through aggression; according to the National Report on the Health of
Children and Young People in Romania [7]
In the United States, more than 12,000 children and teens ages 0-18 die each year
from unintentional and intentional injuries, making trauma the leading cause of death
for this population. [13]
90% of paediatric polytrauma cases are blunt injuries. In these cases, following the
application of force to the young child, multisystem trauma occurs.
To appropriately triage the management of the trauma patient, a useful injury
classification method uses the following parameters:
The extent of Injury - Multi-system trauma is defined by apparent injury to two or
more areas of the body. Localized injuries involve a single anatomical region (e.g.,
head and neck, chest and back, abdomen, extremities) of the body.
Type of injury - Expected injuries differ depending on whether they occur as a result
of blunt trauma (e.g., fall, motor vehicle collision) or penetrating trauma (e.g.,
gunshot, stabbing, shrapnel from an explosion).
The severity of the injury - The mechanism of injury and physical examination
findings are helpful in determining severity. Assessment of severity will dictate initial
management and disposition. [12]
Injury scoring systems have been used for a long time and are helpful for research,
quality improvement, and benchmarking of trauma center. The impact of these scoring

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 systems is particularly important as they need to evaluate scoring systems for different
populations. The Injury Severity Score (ISS), based on the Abbreviated Injury Scale
(AIS), is the best-known scoring system. Although a number of modifications to the
ISS and a number of alternative scoring systems have been proposed, the ISS remains
the most widely used for defining severely injured patients. [8]
A score >15 is used to define severe injuries and for the classification of
patients requiring trauma center care or even full trauma team activation. [10]
For paediatric trauma patients, despite the availability of several scoring systems, ISS
remains the standard. Because there are differences in physiological responses
between children and adults, ISS based on anatomy may lead to an overestimation of
mortality among paediatric patients. The Injury Severity Score (ISS) is a anatomical
score established to assess the severity of injuries and it is correlated with mortality.
[5]
The goals of initial trauma management in children, as in adults, are to rapidly assess
injuries, determine management priorities and provide critical interventions.
Achieving these goals requires a systematic and logical approach in accordance with
Advanced Trauma Life Support (ATLS) principles.
Organizing the medical response around the paediatric trauma team concept can
provide faster identification of injury and faster treatment with improved outcomes.
[2]
Patients with concern for significant intracranial injury or increased intracranial
pressure (IIP) should be managed appropriately to reduce the likelihood of secondary
brain injury from hypoxia, ischemia, and cerebral oedema. [9]
Due in large part to national injury prevention efforts, the overall unintentional
injury death rate for children aged 0-19 years in the United States decreased by 29%
from 2000 to 2009 and remained similar to 2009 levels in 2020 [5]
Objectives 3 The main objective of this study is to identify the main injury mechanism of trauma in
paediatric population.
Methods
Study design 4 The actual study is an analytical and retrospective cohort study,
Setting 5 89 paediatric subjects, presented to the Emergency Department of the Emergency
Hospital of Galati, between January 2015 and December 2021, as victims of a
traumatic events.
Participants 6 The inclusion criteria for this study group were: presence of polytrauma, age lower
that 18 years old (paediatric patients), ER admission between January 2015 and
December 2021. The exclusion criteria were: traumatic events resulting in mono-
trauma, lack of in-jury mechanism. According to the inclusion criteria established at
the beginning of the process, the 89 subjects mentioned above are the result after the
said criteria was applied.
Variables 7 This study aims to investigate the impact of traumatic events on the severity of
polytrauma in paediatric patients admitted to the Emergency Department of the
Emergency Hospital of Galati between January 2015 and December 2021. The
primary outcome of interest is the severity of polytrauma, while the exposure of
interest is the traumatic event that led to the injury. Demographic characteristics such
as age and gender, injury mechanisms, and pre-existing medical conditions are among
the predictors of interest.
However, the relationship between the exposure and outcome may be influenced by
potential confounding factors, including the severity of the injury, co-morbidities, type
of treatment received, and time between injury and hospital admission. Effect

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 modifiers such as age, gender, pre-existing medical conditions, and injury
mechanisms may also play a role in the relationship between the exposure and
outcome.
To assess the severity of polytrauma, diagnostic criteria such as the Injury Severity
Score may be used. Additionally, the length of hospital stay and mortality rates may
also serve as relevant diagnostic criteria. Overall, this study aims to provide insight
into the factors that contribute to the severity of polytrauma in paediatric patients,
with implications for improving treatment and outcomes in this population.
Data sources/ 8* Data sources for this study involve the use of existing medical records, while the
measurement measurement of outcomes and predictors will involve the use of standardized scales
and assessments to ensure accuracy and consistency
Bias 9 It is possible that informational bias may have affected the results of this study.
Informational bias occurs when there are errors or inconsistencies in the measurement
or collection of data. In this study, the severity of polytrauma and potential
confounding factors, such as the type of treatment received, may have been subject to
informational bias if there were inaccuracies or inconsistencies in the medical records.
Additionally, the accuracy of the predictors of interest, such as injury mechanism and
pre-existing medical conditions, may also have been affected by informational bias if
there were errors or omissions in the medical records. To minimize the impact of
informational bias, it is important to use standardized and validated measures and to
verify the accuracy of data through independent sources, where possible.
Study size 10 According to the inclusion criteria established at the beginning of the process, the 89
subjects mentioned above are the result after the said criteria was applied.
Quantitative variables 11 Data collection and processing were carried out respecting the anonymity of the pa-
tients. The opinion of the Bioethics Committee of the Galati County Emergency
Hospital was obtained to access and collect patients' personal information
Statistical methods 12 All the information, once grouped, was then sorted and filtered according to different
criteria. The data obtained from the sample lists were then entered into centralizing
tables (using SPSS IBM statistics V26) and contingency tests and descriptive
statistical analysis were applied.
At the same time, we determined the 95% confidence interval of variation (for the
study of proportions), where appropriate, and in the statistical analysis, we applied the
Chi-square test (χ2) for comparing proportions, and tested the sensitivities of the
diagnostic methods. This allowed us to highlight associations, relationships, and
interdependencies between variables.

Results
Participants 13* At the batch level, the predominance of cases registered in the years 2015-2017 (with
Descriptive data 14* a total of 62.5% of the total number of patients) is noted. The lowest incidences are
Outcome data 15 detected in patients enrolled in the study group in the final period of the statistical
Main results 16 analysis (2020, 2021). 37.5% of the patients are urban.
Other analyses 17 At the group level, the predominance of male subjects will be noted, with an OR of
2:1 (68.2%, compared to approximately 31.8% of female patients).
In terms of the distribution of patients in relation to continuing variables defined as
age (expressed in completed years).
It can be seen that the extremes of the variable defined as age are 3 and 18 years,
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 respectively, with mean age values of 10.26 years (± SD 4.90 years). There is a
median at ap-proximately 9 years of age, with a predominance of patients under 10
years of age. The underlying histogram shows a minimal incidence of cases aged 10-
14 years.
A simplified analysis of the vital parameters obtained from these patients, once they
were admitted to the Emergency Department of the Galati Children's Hospital, was
con-ducted using descriptive analysis elements, on the following variables: Glasgow
score, systolic blood pressure, diastolic blood pressure, ventricular rate, and
respiratory rate.
It is noted that in terms of the Glasgow score, the standard deviation recorded was
4.68 points, with a mean value of 11.84 points. The extremes describe a wide range of
values, between 3 and 15 points respectively.
Blood pressure values, whether diastolic or systolic, show notable deviations from the
mean variable. The subjects' ventricular beats show a mean number of 103.77 heart-
beats per minute (bpm), with an SD of 21.91 bpm.
Predominantly, paediatric patients included in the study group were admitted as
victims of road traffic accidents (62 patients) and patients admitted as pedestrians
involved in road traffic accidents (2 patients). They are followed by those who
suffered polytrauma due to a fall (from another level 7 patient)., and falls from a cart 2
patient).
It is important to remember that paediatric patients presented to the Emergency
Department with trauma of the cephalic extremity, associated with other types of
traumas, from road accidents, falls from height, and hetero-aggressions, were
monitored by the neurologist from the moment of presentation to the Emergency
Department and through-out the duration of hospitalization. Patients were also
periodically neurologically reassessed after discharge for early detection of all
secondary polytrauma disorders.
In the table below (Table 3) we have set out the main differences in the data at the
batch level, depending on the gender of the patients. It will be noted that in terms of
mean age, there are no notable differences (the average age being 10 years). In
particular, in this group of paediatric patients, trauma localized to the cephalic
extremity predominates (either classified as craniocerebral or craniofacial trauma).
For this reason, it will be noted, according to the chi-square test (p = .340), that there
are no statistically significant differences between the sex of the patients and the
incidences of episodes of epistaxis, although they predominate in female subjects.
Hemoperitoneum (3 patients) and haemothorax (4 patients) predominated in males
and 4 patients. Importantly, 3 male patients experienced cardiorespiratory arrest, of
which 2 patients were unresponsive to applied resuscitation manoeuvrers.
The hemoperitoneum had as a mechanism of production by hitting a hard body (the
bike handlebar), road accident, and aggression, the imaging results revealing either
rupture of the renal artery or splenic artery
In this particular batch, numerous radiological investigations were necessary to
quantify the degree of damage to several organs. A total of 15 computer tomography’s
(18.8%), 20% X-rays and 11.3% abdominal and soft-tissue ultrasounds were
performed.

Discussion
Key results 18 In our study, the main way of injury was road traffic accidents (62 patients) and

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pedestrians involved in road traffic accidents (2 patients), followed by accidents
resulting in polytrauma due to falls from another level (7 patients). The majority of
subjects were males, with a mean age value of 10.26 years. There were no significant
relations identified between the patient’s gender and trauma related complications
Prakash Raju KNJ conducted a study in India from September 2015-March 2017 to
describe some of the characteristics of polytrauma among paediatric patients. The
study group consisted of 911 children, aged less than 12 years presenting with various
trauma injuries. [8]
Thus, out of 911 children, 68.2% were male and 30.8% were female. In terms of the
age of the children, almost half of the study group, 49.8% were in the age group of 1-6
years, followed by the 6-12 years group with 39.5% cases. [8] The results are similar
with the ones obtained in our study (68.2% males and 31.8% female patients).
The majority of children suffered injuries at home 63.9% patients.
The main mode of injury in the paediatric population was falling on flat ground
26.9%patients. This was followed by road traffic accidents 232; 25.5% of patients and
falling from height 16.8%patients. Most road traffic accidents occurred when children
were two-wheeled riders (40.5% of patients), followed by pedestrians (31.9% of
patients) [8].
It can be seen that the most common injuries are to the head (384 patients), followed
by injuries to the upper limbs (155 patients) and maxillofacial injuries (85 patients).
[8] (Graphic 3).
By making a correlation between the age of the children and the mode of occurrence
of polytrauma, we can observe that: road traffic injuries are most common in children
aged 6-12 years, followed by falls on flat ground and then falls from a height. For
children under 1 year of age, the main mode of occurrence of polytrauma is falling
from a height, followed by falls from flat ground. [9]
With regard to the scoring system mentioned above, a study conducted from January
1, 2000, to June 30, 2013, in Pennsylvania attempted to provide a description of the
results obtained from its use, as well as some comparisons between the paediatric and
adult populations. [1]
Thus, the study included a total of 402,706 patients, of which: 50,579 paediatric
patients and 352,127 adults. Among children it was observed that they are less likely
to suffer a polytrauma as opposed to adults, thus 42% of all children suffered a
polytrauma, while in adults it occurred in 63% of cases. [1]
Average AIS values in each region and the ratio of single lesions or multiple lesions
according to the study are represented in Table5.
We can also see the difference in mortality between the 2 populations: for a 5%
mortality, adults had an ISS of 15, while children had an ISS of 25. At the same time,
there were differences in mortality in single-system injuries: mortality was similar
when adults had an ISS=15 and children an ISS=26: but also in multi-system injuries:
adults with an ISS=15 had the same mortality rate as children with an ISS=24. [1] It
can be seen that an ISS>25 showed higher specificity as opposed to an ISS>15. (Table
6)
The study was conducted in 11 trauma centers in the Netherlands between 1 January
2010 and 1 January 2016 and included a total of 1623 children, aged 0-18 years, who
had an injury severity score > 15. The results showed a higher frequency of
accidentally occur-ring polytrauma (89%), as opposed to 11% of non-accidentally
occurring polytrauma, but the mortality associated with the latter was higher. A more
detailed analysis was also carried out on children under 5 years of age, revealing that

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 41% of polytrauma
cases in this age group were non-accidental: 10% were provoked and 31% were due to
neglect. [6]
Severe traumatic brain injury is the leading cause of death and disability in children
over one year of age in developed countries. Approximately 98% of patients are mild
in severity; as a result, studies of moderate to severe traumatic brain injury (TBI) are
limited and difficult to conduct. [4]
In another study, an analysis was conducted on the degree of disability following
polytrauma where there is traumatic brain injury among children. M. C. Hernández
conducted a study from October 2002 to October 2017 that included 531 children with
polytrauma, of whom 382 patients had a traumatic brain injury (103 patients had
severe traumatic brain injury). [3]
At 6 months, the functional capacity of the patients was analysed using the Glasgow
Score, as follows: 51% had a satisfactory recovery, 26.5% presented moderate
sequelae, 6.1% had severe sequelae, and 2% vegetative state. In terms of mortality,
14.3% of patients died. [14]
Limitations 19 There are several limitations to this study that should be considered when
interpreting the results.
Firstly, the study sample is limited to paediatric patients who presented to
a single emergency department in Galati, Romania, which may limit the
generalizability of the findings to other populations or settings.
Secondly, there is a potential for selection bias, as the inclusion criteria
may have excluded some eligible patients or included patients who did
not meet the criteria.
Thirdly, there may be a risk of information bias due to errors or
inconsistencies in the medical records used for data collection.
Fourthly, this study is retrospective in nature, meaning that it relies on
data that was already collected and recorded, and therefore lacks the
ability to control for potential confounding factors that were not measured
or recorded.
Finally, this study may be limited by the measurement tools used to assess
the severity of polytrauma and other outcomes, which may be subject to
interpretation and variability across healthcare providers.
Despite these limitations, this study provides valuable insights into the
predictors and outcomes of polytrauma in paediatric patients and may
inform clinical practice and future research in this area.

Interpretation 20 Factors that predispose to paediatric trauma are rarely studied, and currently, there are
no injury prevention programs for the paediatric population. Trauma is a leading cause
of morbidity and mortality in children and adolescents in both developed and
developing countries.
There is significant variation in the mechanism of polytrauma occurrence, severity,
and pattern of paediatric trauma across age groups. The most common injuries are
found in the head, and these are associated with significant mortality for all age
groups.
It has been shown that the main mode of occurrence of polytrauma is road traffic
accidents, followed by falls from heights and assaults. At the same time, it was found

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 that male paediatric patients are more frequently involved in road traffic accidents.
A multidisciplinary approach is necessary and imperative, and patients need to be
managed in specialized centers to optimize care and achieve the most effective
functional recovery.
Generalisability 21 A comparison regarding other literature studies: in pediatric patients with multi-
system injury, peak AIS scores in any affected region except the extremities were
associated with increased odds of mortality. From graphic 6 it can be seen that in head
injuries mortality increases rapidly at AIS=5 in both single and multisystem injuries.
It can also be seen that for abdominal injuries, mortality increases for AIS> 3 in
multiple injuries, but remains relatively low for single abdominal injuries. [1]
Research by Brown JB shows differences performance for ISS in predicting of child
and adult mortality. The explanation for these differences is largely based on the fact
that pediatric patients are more resilient than adults, having a greater physiological
reserve in response to injury. Pediatric patients are therefore better able to compensate
for the same anatomical injury as adults. In conclusion, an ISS>25 may be a more
appropriate definition of severe injury in pediatric trauma patients, as it is a better
predictor of mortality than the conventional definition of ISS>15. [8] Regarding the
mode of occurrence of polytrauma: accidental or non-accidental (provoked or
negligent), Marie-Louise HJ Loos conducted a retrospective study to highlight the
prevalence of each mode and their characteristics.[6]
Other information
Funding 22 This research received no external funding.

*Give information separately for exposed and unexposed groups.

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