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Heart Rate and Posttraumatic Stress in Injured Children

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Heart Rate and Posttraumatic Stress in Injured Children ORIGINAL ARTICLE Heart Rate and Posttraumatic Stress in Injured Children Nancy Kassam-Adams, PhD; J. Felipe Garcia-España, PhD; Joel A. Fein, MD; Flaura Koplin Winston, MD, PhD Background: Elevated, acute heart rate has been re- Main Outcome Measure: Clinician-Administered PTSD lated to later posttraumatic stress disorder (PTSD) de- Scale for Children and Adolescents. velopment in injured adults, but this has not been ex- amined in children and adolescents. Better understanding Results: The group of children who developed partial of the relationship between acute physiological arousal or full PTSD had a higher mean±SD heart rate at ED tri- and later child PTSD could help elucidate the etiology age than those who did not go on to have PTSD of posttrauma responses in children and might identify (109.6±22.3 vs 99.7±18.0 beats per minute). Children useful markers for PTSD risk. with an elevated heart rate (defined as Ն2 SDs higher than the normal resting heart rate for their age and sex) at ED Objective: To evaluate the relationship between heart triage were more likely to meet criteria for partial or full rate assessed in the emergency department (ED) during PTSD at follow-up, even after adjusting for age, sex, and normal clinical care and later PTSD outcome in trau- injury (adjusted odds ratio, 2.4 [95% confidence inter- matically injured children. val, 1.1-5.4]). Design: Prospective cohort study assessed heart rate at Conclusion: These results suggest an association be- ED triage and PTSD an average of 6 months’ postinjury. tween early physiological arousal and the development Setting: Large, urban pediatric academic medical cen- or persistence of PTSD symptoms in injured children and ter in the northeastern United States. point to the importance of better understanding the in- terplay between physiological and psychological func- Participants: One hundred ninety children and ado- tioning after a traumatic stressor. lescents (aged 8-17 years) hospitalized for traffic- related injury. Arch Gen Psychiatry. 2005;62:335-340 OSTTRAUMATIC STRESS REAC- of physiological functioning and immedi- tions are a common conse- ate responses to traumatic events may help quence of pediatric injury, elucidate the etiology of posttraumatic with a significant minority of stress responses. A recent meta-analysis injured children going on to documents an association between chronic Author Affiliations: develop posttraumatic stress disorder PTSD and elevated basal heart rate,11 but TraumaLink: The Pediatric P1-6 (PTSD). Recent investigations have ex- our knowledge of the prospective course Interdisciplinary Injury Control plored early predictors of persistent trau- of this relationship is far more limited. Sec- Research Center (Drs Kassam-Adams, matic stress in order to identify, during ond, if heart rate data were shown to re- Garcia-España, Fein, and acute medical care, those children in need liably aid in the prediction of later PTSD, Winston), Center for Pediatric of further assessment and possible inter- this might serve as a fairly simple and Traumatic Stress, Department of vention.6,7 For traumatically injured adults, straightforward marker of risk to identify Psychology (Drs Kassam- several investigators have found an asso- those in need of further assessment after Adams, Fein, and Winston), ciation between elevated heart rate dur- the occurrence of a traumatic event. Division of Biostatistics ing acute medical care and later develop- Although elevated heart rate in the im- (Dr Garcia-España), The ment of PTSD.8-10 The relationship between mediate aftermath of a traumatic event has Children’s Hospital of early postinjury heart rate and later PTSD been related to later PTSD development Philadelphia, Divisions of has not been examined in children. in adults,8-10 to our knowledge, no pub- Emergency Medicine (Dr Fein), and General Pediatrics The potential relationship between lished study has examined the relation- (Dr Winston), Department of heart rate assessed in the first hours or days ship between acute heart rate and later Pediatrics, the University of after a traumatic event and later PTSD out- PTSD outcome in children exposed to trau- Pennsylvania School of come is of interest for several reasons. First, matic events. A challenge in studying this Medicine, Philadelphia. understanding the course and trajectory in children and adolescents is the devel- (REPRINTED) ARCH GEN PSYCHIATRY/ VOL 62, MAR 2005 WWW.ARCHGENPSYCHIATRY.COM 335 ©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 opmental trend in normative resting heart rates across MEASUREMENT OF POSTTRAUMATIC childhood. Resting heart rates are higher in younger chil- STRESS OUTCOME dren and decrease through early adolescence. For ex- ample, the mean heart rate for children aged 8 to 11 years The PTSD symptoms and diagnostic status were evaluated us- is 91 beats per minute (BPM); between the ages of 12 and ing the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA), a semistructured interview with es- 15 years, children’s normative resting heart rates are simi- 14 lar to adults, at 85 BPM.12 A further challenge for study- tablished reliability and validity for assessment of child PTSD that yields scores for both continuous symptom severity ing heart rate in recently injured children is the poten- (CAPS-CA total score) and categorical diagnostic outcome. Three tial impact on heart rate from the injury itself, its levels of categorical PTSD outcome were defined: (1) “full physiological aftermath, and any emergency treatment PTSD”: meeting DSM-IV15 symptom criteria for PTSD, (2) “par- procedures or medication. In addition, when heart rate tial PTSD”16: at least 1 moderate to severe posttraumatic stress is assessed at emergency department (ED) triage, the ac- symptom in each of the 3 PTSD symptom categories (reexpe- tual time elapsed since the occurrence of the injury may riencing, avoidance, and hyperarousal) and functional impair- differ among patients. These variations (age, injury ef- ment from these symptoms, and (3) “no PTSD”: did not meet fects, timing) have the potential to create “noise” in the either of these standards. Partial PTSD has been shown to be clinically meaningful and associated with significant dis- data that could obscure relationships between ED heart 16-18 rate and posttraumatic stress outcomes. Nonetheless, the tress, and investigators have found partial PTSD in a sig- nificant minority of children following traumatic injury.5 promise of a straightforward early risk marker for child posttraumatic stress that can be applied in a real-life set- ting makes the relationship between ED heart rate and OTHER MEASURES later PTSD outcome a compelling research question. The current prospective study examines the relation- Information regarding demographics, hospital admission, and the child’s injuries was abstracted from the medical record and ship between heart rate and PTSD in injured children. the hospital’s trauma registry. Injury information included Ab- We hypothesized that (1) heart rate assessed at ED tri- breviated Injury Scale scores and the Injury Severity Score.19,20 age would be related to later PTSD outcome in traumati- The Abbreviated Injury Scale and Injury Severity Score are widely cally injured children and that (2) the relationship be- used to classify injury severity in terms of threat to life; both tween heart rate and PTSD outcome would remain have proved reliable and valid as measures of injury severity significant after controlling for child age, sex, and the pres- in children.21 The Abbreviated Injury Scale rates the severity ence of a severe injury. of an anatomical injury from 1 (minor injury) to 6 (fatal in- jury) for each of 6 body regions. An Abbreviated Injury Scale score of 2 or greater is considered clinically important (eg, con- METHODS cussion, fracture, or abdominal organ injury). The Injury Se- verity Score is a well-recognized measure of overall injury se- Children admitted to a level I pediatric trauma center were verity; Injury Severity Scores higher than 19 generally represent enrolled in a prospective study of posttraumatic stress after severe injury. injury. Following an institutional review board–approved pro- tocol, all children between the ages of 8 and 17 years admitted for treatment of traffic-related injuries sustained as a pedes- STATISTICAL ANALYSES trian, passenger, or bicyclist were eligible for inclusion. An ED triage nurse assessed the heart rate in a private triage area. Demographics, injury characteristics, and heart rate of partici- Child posttraumatic stress was assessed at least 3 months’ pants completing vs not completing follow-up assessment were compared using t tests or Wilcoxon rank sum tests for con- postinjury in a follow-up assessment conducted in the child’s ␹2 home. tinuous variables and or Fisher exact tests for categorical vari- ables. Heart rate data were examined in 2 different ways. First, we compared mean ED triage heart rate (BPM) between the MEASUREMENT OF HEART RATE no PTSD, partial PTSD, and full PTSD groups with analysis of variance followed by post hoc tests for group differences. Sec- Triage heart rate was assessed as part of standard clinical care ond, Fisher exact test, ␹2,ort tests were used to examine the within 5 minutes of the child’s arrival at the ED, using 1 of 3 association of elevated heart rate at ED triage with dichoto- methods: cardiac auscultation, radial pulse palpation, or an au- mous, categorical, and continuous PTSD outcome measures, tomated vital-signs monitoring device (Critikon Dinamap; Cri- respectively. Sensitivity, specificity, positive predictive value tikon, Tampa, Fla). Standard deviation scores (“heart rate z (PPV), and negative predictive value (NPV) were calculated scores”) were calculated for heart rate compared with age and for elevated heart rate as a predictor of PTSD status. The PPV sex norms in order to have an alternate measure of heart rate is the probability that a child with an elevated heart rate will that was not affected by normative age differences.
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