Trends in mortality rates in hypotensive pediatric trauma patients undergoing emergent trauma laparotomy

BACKGROUND: Massive hemorrhage remains the leading cause of preventable death after pediatric trauma. Emergent trauma laparotomy (ETL) is a common operation to obtain hemorrhage control. Mortality rates for adult patients in hemorrhagic shock requiring ETL remain high and unchanged. Information on mortality rates after ETL in pediatric patients is limited. We sought to evaluate trends in mortality rates for pediatric ETL patients. METHODS: The National Trauma Data Bank (NTDB) was queried from 2007 to 2023. Patients aged 0 to 18 years old were included if they underwent ETL. ETL was defined as laparotomy within 1 hour of arrival. Hypotension was defined as a systolic blood pressure <90 mm Hg on arrival. The primary outcome was annual hospital mortality rates for hypotensive patients requiring ETL. Secondary outcomes included annual 24-hour mortality rates for both hypotensive and all patients requiring ETL. Mortality rates were compared in 5-year cohorts to reduce annual variability. RESULTS: A total of 11,374 patients underwent ETL. The majority of patients were male (79%; n=78,963/11,374). Most patients were between the ages of 12 and 17 (84%; n=9,565/11,374), followed by ages 5 to 11 (11%; n=1,227/11,374), then ages 0 to 4 (5%; n=582/11,374). Penetrating injuries predominated (69%; n=7,866/11,374). The hospital mortality rate for all patients was 18.3% (n=2,079/11,374). Of patients who died, 74% were within 24 hours of arrival (n=1,533/2,079). Overall, 19% (n=2,125/11,374) were hypotensive on arrival. For hypotensive patients, the 24-hour and hospital mortality rates were 30% (n=641/2,125) and 45.9% (n=976/2,125). There was year-to-year variability in rates of hospital mortality of hypotensive patients through the study period (p<0.001). However, the average mortality rates from 2007 to 2011 (45%; n=293/645) and 2019 to 2023 (42%; n=266/638) were unchanged (p=0.95). CONCLUSIONS: Pediatric trauma patients with exsanguinating hemorrhage requiring ETL continue to suffer high rates of mortality. These findings underscore the urgent need for targeted research and performance improvement. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.