Pediatric Annals

Pediatric Trauma: Initial Evaluation and Stabilization

D L McCarty, MD, FACEP; J S Surpure, MD, FAAP, FACEP

Abstract

Trauma is the leading cause of childhood mortality. In children between the ages of 1 and 14, accidents account for approximately as many deaths as all other causes combined. High morbidity results as well - pediatrie injuries result in 2 million hospitalizations and 50 000 permanently handicapped children annually. Rapid provision of quality initial care greatly improves the chances for satisfactory recovery from injury. Skill in the initial management of trauma is vital for practitioners of pediatrie emergency medicine.

In recent years, trauma care in the United States has improved markedly. The impetus provided by the Vietnam experience is largely responsible for this improvement. The contrast between the excellence of care on the battlefield with the deplorable conditions prevailing in the civilian sector brought national attention to the problem. Subsequently, trauma care has been improved and new standards have been developed. Through means such as advanced trauma life support (ATLS) courses, the knowledge has been made widely available. Most physicians today are well aware of the general principles of trauma care.

Unfortunately, the importance of trauma in childhood is not always appreciated. Historically, trauma care originated on the battlefield, and traumatic injuries in adults have always been far more common than in children. However, increasing industrialization and the spread of violence have made childhood injury much more prevalent today. Nevertheless, clinical practice and scientific literature continues to reflect an adult bias, fortunately, many underlying principles of trauma care are the same, but emergency physicians must be aware of the unique features of pediatrie trauma to avoid mistakes that can result from treating children as "small adults."

APPROACH TO TRAUMA CARE

Trauma resuscitation demands a team approach.1 This team may vary in size, experience, and abilities, but every member must understand his function or chaos will ensue. Each facility should formulate policies for dealing with trauma, and personnel should be oriented to their individual therapeutic roles in advance. A senior team member should serve as "captain of the ship," charged with responsibility for and coordination of the activities of the various personnel involved and the overall care of the patient. Trauma care is complex and frequently requires a multidisciplinary approach; if no one is in charge of setting PnOrUiCS7 oversights and confusion can result.

Trauma care begins in the field. Properly trained emergency medical services (EMS) personnel are essential for optimum outcome. They must be able to begin stabilization measures on the scene of the accident and to extricate and transport victims safely. Ideally, they should serve as triage agents for a regional trauma system with a designated pediatrie trauma center, allowing victims to be transported to a facility that is appropriate for the severity of injury (not necessarily the nearest hospital). Trauma scoring systems have been developed to facilitate appropriate triage. Recently, the Pediatrie Trauma Score (PTS; Table 1), developed specifically to reflect the types and patterns of injury seen in childhood, was demonstrated to be practical and teliable for field triage.2 A score lower than 8 is an indication for triage to a regional pediatrie trauma center; scores of 6 or less are associated with increased morbidity and mortality; while scores less than 2 predict death in all cases.

Eacilities that receive trauma victims must commit appropriate patient care resources. Adequate numbers of well-trained personnel must be available. Pediatrie trauma care is too important to delegate to inexperienced junior team members, despite the fact that injuries tend to occur at inconvenient hours. All members of the trauma team (including nonphysicians) should be aware of the relative priorities, or the ABCs, of trauma resuscitation (Table 2) and of life-saving emergency…

Trauma is the leading cause of childhood mortality. In children between the ages of 1 and 14, accidents account for approximately as many deaths as all other causes combined. High morbidity results as well - pediatrie injuries result in 2 million hospitalizations and 50 000 permanently handicapped children annually. Rapid provision of quality initial care greatly improves the chances for satisfactory recovery from injury. Skill in the initial management of trauma is vital for practitioners of pediatrie emergency medicine.

In recent years, trauma care in the United States has improved markedly. The impetus provided by the Vietnam experience is largely responsible for this improvement. The contrast between the excellence of care on the battlefield with the deplorable conditions prevailing in the civilian sector brought national attention to the problem. Subsequently, trauma care has been improved and new standards have been developed. Through means such as advanced trauma life support (ATLS) courses, the knowledge has been made widely available. Most physicians today are well aware of the general principles of trauma care.

Unfortunately, the importance of trauma in childhood is not always appreciated. Historically, trauma care originated on the battlefield, and traumatic injuries in adults have always been far more common than in children. However, increasing industrialization and the spread of violence have made childhood injury much more prevalent today. Nevertheless, clinical practice and scientific literature continues to reflect an adult bias, fortunately, many underlying principles of trauma care are the same, but emergency physicians must be aware of the unique features of pediatrie trauma to avoid mistakes that can result from treating children as "small adults."

APPROACH TO TRAUMA CARE

Trauma resuscitation demands a team approach.1 This team may vary in size, experience, and abilities, but every member must understand his function or chaos will ensue. Each facility should formulate policies for dealing with trauma, and personnel should be oriented to their individual therapeutic roles in advance. A senior team member should serve as "captain of the ship," charged with responsibility for and coordination of the activities of the various personnel involved and the overall care of the patient. Trauma care is complex and frequently requires a multidisciplinary approach; if no one is in charge of setting PnOrUiCS7 oversights and confusion can result.

Trauma care begins in the field. Properly trained emergency medical services (EMS) personnel are essential for optimum outcome. They must be able to begin stabilization measures on the scene of the accident and to extricate and transport victims safely. Ideally, they should serve as triage agents for a regional trauma system with a designated pediatrie trauma center, allowing victims to be transported to a facility that is appropriate for the severity of injury (not necessarily the nearest hospital). Trauma scoring systems have been developed to facilitate appropriate triage. Recently, the Pediatrie Trauma Score (PTS; Table 1), developed specifically to reflect the types and patterns of injury seen in childhood, was demonstrated to be practical and teliable for field triage.2 A score lower than 8 is an indication for triage to a regional pediatrie trauma center; scores of 6 or less are associated with increased morbidity and mortality; while scores less than 2 predict death in all cases.

Eacilities that receive trauma victims must commit appropriate patient care resources. Adequate numbers of well-trained personnel must be available. Pediatrie trauma care is too important to delegate to inexperienced junior team members, despite the fact that injuries tend to occur at inconvenient hours. All members of the trauma team (including nonphysicians) should be aware of the relative priorities, or the ABCs, of trauma resuscitation (Table 2) and of life-saving emergency procedures which may be needed, such as vascular access, intubation, or thoracostomy (Table 3). At least one team member who is skilled in trauma procedures and initial stabilization must be available at all times. The operating suite must also be readily available 24 hours a day; delays in surgery can result in avoidable mortality.

Obviously, not all facilities can provide comprehensive trauma care. Where possible, regional EMS systems should establish policies that allow accurate triage and transport to the most appropriate facility. In rural areas, emergency physicians must be prepared to stabilize life-threatening conditions and to arrange prompt transfer to appropriate facilities for definitive care. Contingency plans and prearranged referral agreements between institutions are of particular benefit in this situation. Guidelines for the stabilization and transport of critically injured children have been published.3 Individual trauma physicians must have an adequate knowledge base and motor skills sufficient for performing the emergency procedures listed in Table 3. Additionally, interpersonal skills are important in functioning as part of a team and for dealing with the emotional needs of children and their parents.

INITIAL EVALUATION

Trauma care must proceed in an organized, systematic fashion; with frequent repetition, procedures should become "second nature" to trauma team members. The American College of Surgeons advocates dividing the evaluation into primary survey, resuscitation, secondary survey, and definitive care phases4; this may be considered the standard method of organization. The ABCs approach outlined in Table 2 serves as a well-recognized and easily recalled guide to treatment priorities.

All pediatrie trauma patients must be presumed to have significant injury until proven otherwise. In contrast to conventional medical diagnosis, the patient must be "worked down" (instituting treatment first and obtaining the history last) rather than "worked up" (obtaining a full history, physical examination, and laboratory tests before instituting therapy). Knowledge of the mechanism of injury may allow anticipation of inj uries likely to be present. 5 Ibr example, a child hit by a car is likely to have head and extremity injuries, whereas chest injury is much less common than in the adult victim.6 Time factors dictate aggressive management; the trauma physician cannot wait until patient deterioration confirms the impression that this might occur. The physician must assume that deterioration will occur unless intervention is undertaken. Airway or circulatory compromise, neurologic or vascular injury, and renal failure are better treated or prevented with early recognition and intervention.

Because traumatic injury is a dynamic process that may produce rapid changes in the patient's status, frequent révaluations are mandatory. An airway that was initially adequate may become obstructed by blood or secretions. Ongoing blood loss may cause hemodynamic deterioration. A tension pneumothorax may develop rapidly. Neurologic deterioration from an intracranial hematoma must be recognized immediately. Important findings may be overlooked on a single exam. Therefore, serial examinations and révaluations are absolutely essential for adequate trauma management.

Table

TABLE 1Pediatrie Trauma Score

TABLE 1

Pediatrie Trauma Score

Trauma may be classified as blunt (typically from falls or vehicular accidents) or penetrating (gunshot wounds, stabbings). Although recent trends indicate a disturbing increase in gunshot wounds, blunt trauma remains more common in children. Unfortunately, it is generally more challenging to evaluate. Penetrating trauma usually affects organs and tissues in the direct path of the wounding instrument, whereas the effects of blunt trauma may be more widespread and less obvious. Most of the discussion here will be directed toward blunt trauma, but the general approach is the same for penetrating trauma.

Primary Survey

The primary survey begins immediately and is directed at the identification of immediate threats to life. The first priority is ensuring an adequate airway, while protecting the cervical spine from injury. If the child is breathing spontaneously, a chin lift or jaw thrust is carried out, secretions and debris are cleared from the mouth and pharynx, and supplemental oxygen is administered. Tilting of the head dorsal Iy is avoided when cervical spine injury is a possibility. The neck should be immobilized, although this may be difficult to accomplish in an uncooperative small child. Immobilization is best achieved using a spine board combined with sandbags or, if available, a properly fitting rigid cervical collar. Once the mouth and pharynx are cleared, an oral or nasopharyngeal airway may be placed; the former should be placed under direct vision using a tongue blade.

Table

TABLE 2The ABCs of Trauma

TABLE 2

The ABCs of Trauma

Table

TABLE 3Emergency Procedures Needed to Sustain Lite In Trauma Victims

TABLE 3

Emergency Procedures Needed to Sustain Lite In Trauma Victims

If the patient is apneic or basic resuscitation measures fail to restore adequate ventilation, an endotracheal airway must be placed. Orotracheal intubation under direct vision is the most reliable means of ventilating children with airway compromise. The cervical spine must be protected by in-line manual immobilization without traction. Nasotracheal intubation is not recommended for children, although it is the preferred method for intubation of adults with potential cervical spine injuries. Instead, an uncuffed oral endotracheal tube should be used for children under the age of 8. The appropriate tube size should approximate the diameter of the child's external nares or fifth finger. Sellick's maneuver (gentle pressure on the cricoid cartilage pushing it posteriorly) may aid in preventing aspiration by occluding the esophagus as the larynx moves posteriorly, where it may be visualized more easily. Care should be taken not to produce hypoxia by prolonged attempts at intubation without providing intermittent ventilation; having the intubator hold his own breath during each intubation attempt helps to prevent this. The tip of the endotracheal tube should be positioned 2 to 3 cm below the vocal cords. The trachea! position of the tube is confirmed by careful auscultation, adequate bilateral chest excursions, and noting the fogging of the tube through exhaled water vapor, followed by radiography to determine the exact position of the tube as soon as possible. Recently, end-tidal CO2 detectors that reliably detect exhaled carbon dioxide have become available for emergency department use; detection of exhaled carbon dioxide with a litmus-type marker placed between the proximal end of the endotracheal tube and the breathing bag) that changes from a purple to yellow color when CO2 is exhaled indicates proper tracheal positioning with a high degree of positivity.7 These CO2 detection devices can also be used to detect subsequent endotracheal tube dislodgement or occlusion.

Rarely, when all intubation attempts fail, creation of an airway surgically is necessary. In pediatrics, this is a controversial topic. Cricothyroidotomy, the surgical airway of choice for adult patients, is difficult and hazardous to perform in children. Tracheostomy is time consuming, hazardous (in emergency situations), and requires considerable surgical skill. Needle jet insufflation using a ?-bore needle inserted through the cricothyroid membrane is considered by most to be the surgical method of choice for emergency airway access in children. Due to inadequate ventilation with consequent CO2 retention, this method should be used only temporarily. A definitive airway (surgical tracheostomy) must be provided within 45 minutes to 2 hours, following appropriate stabilization and preparation when endotracheal intubation is not possible. An additional disadvantage of needle jet insufflation is that the airway is not protected from aspiration. Some physicians, therefore, prefer an emergency tracheostomy procedure,8 whereby an incision is made between two trachea! rings and an airway is inserted in the opening. This method, however, is not recommended except as a last resort.

Special intubation techniques, such as fiberopticaided intubation, use of a lighted stylet, retrograde intubation, and digital intubation, have been used in adults9; however, little information is available on the use of these techniques in pediatrie patients.

After the airway is secured and the cervical spine protected, adequate ventilation must be ensured. In children, adequate tidal volumes can be achieved with a bag-valve-mask apparatus. Oxygen -powered devices, or "air demand valves" connected to endotracheal tubes are contraindicated. The ideal method for maintaining a child's airway is to maintain the head in the "sniffing" position; however, overextension of the neck to achieve this positioning may produce upper airway obstruction in unintubated patients.

The next priority is circulation. Visible hemorrhage is controlled with direct pressure; clamps and tourniquets are avoided. Signs of shock should be sought: pulses are palpated, skin temperature and color noted, and the level of alertness ascertained. Because children have a larger physiologic reserve than adults, signs of shock may be very subtle and require careful examination to elicit. Infants may be even more difficult to evaluate. 10 Shock may be manifested as abnormalities of the respiratory rate, metabolic instability, skin mottling, or erratic vital signs. The relatively smaller vascular volume of the pediatrie victim leaves less margin for error. Once a critical amount of blood is lost, a child who has appeared to be relatively stable may deteriorate rapidly.

Vascular access must be obtained for circulatory support. Unfortunately, this may be difficult to achieve in pediatrie patients, particularly in the presence of shock with its concomitant vasoconstriction. Two peripheral intravenous lines of the largest practical caliber are recommended. If these cannot be rapidly placed percutaneously, alternatives include a peripheral vein cutdown and an intraosseous infusion. Cutdowns are time consuming, a considerable drawback in an emergency situation. Intraosseous infusions have been gaining popularity for this indication. Any large-bore needle may be used, but bonemarrow and specially developed intraosseous needles are optimal. The preferred site of insertion is approximately 2 cm below the tibial tubercle. The needle is inserted perpendicular to the flat medial surface of the bone with slight angulation away from the growth plate. A rotary motion and firm pressure are used, and entrance into the marrow cavity is indicated by a sudden loss of resistance to the needle's penetration. To avoid extravasation, care must be taken not to puncture the opposite side of the bone; multiple attempts at the same site should be avoided. Central venous line placement in children is hazardous and should be attempted only as a last resort. Given the importance and frequent difficulty of achieving vascular access, a predetermined standard protocol with defined time limits can be of great benefit in trauma resuscitation (eg, if no peripheral access within 5 minutes, proceed with intraosseous puncture).

A brief evaluation of the child's neurologic status is the next priority. In the primary survey, this consists simply of noting the response to stimuli and examining the pupils. The patient is classified as being fully alert, responding to voice, responding to pain, or unresponsive. The pupils are checked for size, symmetry, and briskness of response to light.

An essential part of the primary survey is exposure. All victims must be fully unclothed or significant injuries will be missed. This is especially true for the back and perineal areas. Concern for patient modesty or damage to clothing is misplaced, although explanations to patient and family should be provided.

Table

TABLE 4Resuscitation Phase Checklist

TABLE 4

Resuscitation Phase Checklist

Resuscitation Phase

For convenience, this phase is separated from the primary survey. In reality however, many of the procedures described are carried out simultaneously; Ufesavirvg modalities are instituted as the problems are identified, rather than at the conclusion of the primary survey. An experienced trauma team is able to integrate these phases smoothly and efficiently. The team captain may pause briefly to ensure that all indicated steps have been carried out before proceeding with the secondary survey (Table 4).

Supplemental oxygen in high concentration (FiO2 of 0.85 or greater) is administered to all trauma patients. R>r nonintubated patients, achieving this concentration requires use of a 100% rebreathing mask reservoir.

Intravenous access should be assured, and blood (obtained at the time of venipuncture) sent for typing, crossmatching, and appropriate baseline electrolyte and blood gas determinations. For hypovolemic patients, an initial Ringer's lactate bolus solution of ZO cc/kg (which may be repeated up to three times) should be given and surgical consultation obtained. Should the patient remain hemodynamically unstable, packed red blood cells (10 cc/kg) should be administered; ongoing bleeding requiring emergency surgery is likely. Massive hemorrhage may require immediate transfusion prior to completion of crossmatching; type-specific blood may be given with minimal delay and only a small risk of adverse reaction. The need for universal donor (O negative) blood is rare; type-specific blood can be available within 1 5 to 20 minutes. If stability is achieved at this point, further diagnostic evaluation is feasible.

Vital signs are assessed during this phase and are interpreted with consideration of the patient's age. Normal blood pressure does not rule out shock. Children may tolerate losses of 25% of blood volume without significant hypotension. A more sensitive indicator is tachycardia, although pain and anxiety alone may be responsible. Shock must be carefully excluded when the heart rate is elevated. Abnormal respiratory rate and effort indicate cardiorespiratory dysfunction. Measurement of body temperature is extremely important or hypothermia may otherwise be easily overlooked. Children (especially infants) do not tolerate cold environments or intravenous fluids well - they lose heat rapidly because of their relatively large body surface area. Hypothermia adversely affects cardiovascular function and should always be considered and corrected in trauma patients by covering exposed body parts or by using radiant warmers. Electrocardiographic monitoring allows rapid assessment of changes in heart rate; in children this is especially important for evaluating cardiovascular status. Pulse oximetry and capnometry, if available, are useful noninvasive monitors of respiratory function in seriously ill patients.

A nasogastric tube or catheter should be placed. If passage of the tube through the nose is contraindicated because of a possible basilar skull fracture, oral placement should be accomplished. Gastric dilatation is common in pediatric trauma victims and can lead to emesis with aspiration; a distended stomach may interfere with respiratory function by limiting diaphragmatic excursion. Fresh blood may be present in the stomach, indicating possible injury to the gastrointestinal tract. This placement of a gastric tube to aspirate air and fluid from the stomach and to keep it empty is of great importance.

Placement of a Foley catheter is essential for monitoring urine output in pediatric trauma victims. Central venous monitoring is hazardous. Signs of shock may be subtle, and urine output is a good indicator of end-organ perfusion. Blood at the urethral meatus, scrotal or labial hematomas, a displaced prostate gland, or difficulty in catheter advancement contraindícate placement of a Foley catheter until the integrity of the lower urinary tract can be demonstrated with intravenous pyelography. Urinary output should be maintained at 2 cc/kg/hr.

Essential radiographs using portable x-ray equipment may be obtained during the resuscitation phase. A lateral cervical spine radiograph should be obtained as soon as possible using manual in-line immobilization without traction. Radiographs of the chest and pelvis are recommended for all cases of significant blunt trauma. Radiologic evaluation is directed at determining conditions that are of immediate therapeutic importance (eg, hemothorax). No attempt should be made to obtain films that are not pertinent to resuscitation and stabilization (eg, a facial series), and obtaining even important diagnostic radiographs should not interfere with resuscitati ve measures.

Frequently, enough information is available at this point to indicate the need for surgical consultation (usually with general surgeons or neurosurgeons) or transfer to a higher level trauma care facility. Arrangements for this can be made while further evaluation is proceeding.

Secondary Survey

The secondary survey is a head-to-toe evaluation to identify all significant injuries. Inspection, auscultation, and palpation ("look, listen, and feel") are carried out over each segment of the body.

The survey begins with the head. Deformities, lacerations, bleeding, and cerebrospinal fluid leaks are sought. Open wounds should be palpated or probed (with sterile gloves) for fractures or foreign bodies. The eyes are examined for signs of injury, for visual acuity, and for fundoscopic changes. Maxillofacial trauma, unless causing airway obstruction, should be dealt with later, and should not be allowed to distract the physician from more important, immediate priorities.

Examination of the neck is of great importance. All patients with injury above the clavicle are suspect for cervical spine injury, which must be ruled out radiographically. The absence of neurologic deficit does not rule out cervical spine injury. If the lateral radiographic view is negative for fracture or dislocation, a full cervical spine series should be obtained. The soft tissues of the neck and the larynx should also be examined. Penetrating wounds of the neck should not be probed or explored in the emergency department to avoid dislodgement of clots with concomitant hemorrhage and the risk of introducing infection to the deep tissues of the neck.

Examination of the chest follows. Adequacy and symmetry of respiratory efforts are noted. Suspicion of tension pneumothorax warrants immediate needle aspiration of the thorax, inserting the needle through the anterior second intercostal space of the affected side followed by tube thoracostomy. A roentgenogram of the chest should be carried out in all cases of multiple trauma. The absence of rib fractures does not rule out significant parenchymal injury.

Abdominal evaluation can be very difficult. The physical examination can be insensitive, but any positive findings should be viewed seriously. Serial examinations, frequent surgical consultations, and abdominal computerized tomography scans constitute the cornerstones of diagnosis. In unstable patients, a "one-shot" intravenous pyelogram should be performed prior to or during exploratory laparotomy. 1

Table

TABLE 5Glasgow Coma Score

TABLE 5

Glasgow Coma Score

Rectal (and sometimes vaginal) examinations are also essential. The presence of rectal or vaginal lacerations alters the surgical approach significantly, and, if undetected, may lead to contamination of the entire peritoneum. Sphincter tone is an important indicator of spinal cord function.

Examination of the extremities identifies contusions, lacerations, deformities, and diminished or absent pulses. Appropriate radiographs, including at least two views perpendicular to each other, should be obtained at this time.

The back must be examined. This may require "log-rolling" the patient. If suspicion of a spinal fracture exists, cross-table lateral radiographs of the thoracic and lumbar spines should be obtained and evaluated before this maneuver is performed.

Neurologic examination is carried out in a more comprehensive manner. Motor and sensory exams are performed. The pupillary responses and level of consciousness are reevaluated. A Glasgow coma score (Table 5) should be recorded as a baseline measure, against which improvement or deterioration of the level of consciousness can be made, and as a predictor of eventual central nervous system function. Computerized tomography of the head should now be considered for significant intracranial injuries. Skull radiographs are of very limited benefit and obtaining them should never delay treatment. Magnetic resonance imaging, despite its greater resolution and sensitivity, does not provide information affecting acute care of the patient and is difficult to use in the emergency setting.

Table

TABLE 6Circumstances Likely to Require Transfer to a Pediatric Trauma Center

TABLE 6

Circumstances Likely to Require Transfer to a Pediatric Trauma Center

DEFINITIVE CARE PHASE

Once the patient is stabilized and has been reassessed, decisions regarding definitive care must be made. Depending on the capabilities of the treating facility, these may include immediate surgery, hospitalization locally, or transfer to a higher level treatment center, such as a university hospital pediatric intensive care unit or a trauma center, factors to be considered in disposition decisions are similar to those used in field triage - severity of injuries, age, transport time, and treatment capabilities at the primary facility. A common recommendation is that patients with a pediatric trauma score of less than 8 or a Glasgow coma score of less than 1 3 are best treated in a pediatric trauma center.12 Considerable evidence has been accumulated that such centers do, in fact, reduce morbidity as well as mortality.13 Table 6 lists the circumstances that are likely to require transfer of severely injured children to a pediatric trauma center. If the patient is either hospitalized locally or transferred, appropriate consults should be arranged expeditiously. The responsibility for arranging these should be clear; most often this rests with the general surgeon managing the case, but the emergency department physician may facilitate the process by mutual consent.

If at any point during initial stabilization and evaluation, it becomes apparent that transfer will be required, arrangements should be instituted immediately. The evaluation of severely injured children needing immediate transfer to a higher level trauma care facility may be less than comprehensive; however, all life-threatening injuries must be identified and stabilized (within the capabilities of the transferring physician and institution) prior to transport. A prearranged transfer checklist similar to that shown in Table 4 should be used. Consideration of the method of transport (air vs ground) is also important. Air transport may be faster and generally offers high-quality care en route but may not be available due to poor weather conditions, maintenance problems, or commitment to other transports. Interhospital triage agreements help facilitate the transfer process.

SPECIAL FEATURES OF PEDIATRIC TRAUMA

Certain aspects of trauma care specific to children should be appreciated. Some relate to general principles and have already been addressed, others require a more detailed discussion. Biophysical, epidemiologic, and psychosocial differences produce manifestations of trauma different from those present in adults.

Biophysical factors include anatomic and physiologic differences. The smaller size of the child dictates that the same amount of traumatic force is distributed over a smaller area, and the child's viscera are closer to the body surface; thus, severe injury may result from lower energy impacts. Pediatric connective tissue is more resilient, having more flexibility and resistance to shearing stresses. Injuries occurring as a result of shear stress, such as aortic dissection, are uncommon. The absence of fractures and lacerations cannot be interpreted to indicate a lack of significant trauma. Conversely, the relative flexibility of the skeleton and its supporting elements allows increased transmission of forces to internal organs, ibr instance, pulmonary contusions frequently occur in the absence of rib fractures. 0( course, when fractures or lacerations are present in a multiply traumatized child, one must conclude that considerable force was applied.

Uncomplicated fractures and lacerations in children tend to heal more rapidly and satisfactorily, so that open surgical fracture management is seldom necessary. Initial burn management generally follows the same principles as those used for adults, although the greater fluid requirements, temperature change intolerance, and differing psychosocial needs of children (including consideration of possible child abuse) require more frequent referrals to burn centers.

In addition to the different fluid requirements and thermoregulation difficulties, small children have less ability to maintain acid-base balance. Lactic acidosis resulting from shock may easily deplete available acid-base buffers. Arterial blood gases and serum bicarbonate levels should be followed closely in seriously injured children.

Children have a relatively large head-to-body ratio and short stature, producing a higher center of gravity. In an automotive deceleration event (crash or sudden stop), the child, unless restrained, tends to fly through the air, hitting the dashboard or windshield, whereas an adult tends to "submarine" beneath the dashboard. This contributes to a higher rate of head injuries in children involved in low speed impacts. The neck muscles are weaker, absorbing less force, and rendering the brain more vulnerable to shearing stress (as in the shaken-baby syndrome). The brain is much more prone to develop a cerebral edema, which may occur early or late, even in apparently mild head injuries. In contrast, fewer intracranial hematomas occur. Computerized tomography of the cranium is essential in determining the need for surgery in significant head injuries. Management of cerebral edema is even more important in children and frequently requires monitoring of intracranial pressure. Neurologic recovery from comparable injuries is much better in children; however, the child's brain is more vulnerable to secondary injury from hypoxia, hyperthermia, and seizures, and prevention and treatment of these problems deserves a high management priority.

The neck of a child is relatively short, allowing more flexibility than that of an adult. Consequently, cervical spine injuries are relatively rare in children. The injuries to the cervical spine that do occur tend to be located at higher levels. Because the child's weaker muscles offer less support, ligamentous injuries without fracture and cord injuries without cervical spine injury are more frequently seen. Isolated injuries to the lower cervical spine are uncommon; if one is seen, an unappreciated injury at a higher level should be suspected. A frequent finding in an unfractured pediatric cervical spine is an apparent subluxation at its upper level; careful evaluation is necessary to differentiate this "pseudoSubluxation" from a true injury. Soft tissue "swelling" of the neck is a less reliable finding in children than in adults; crying, swallowing, forceful respirations, or enlarged lymph nodes may mimic swelling due to cervical spine injury. The odontoid process may be incompletely ossified, mimicking a fracture on radiographic examination. Whenever there is doubt as to the presence of a neck injury, immobilization of the neck should be maintained and radiographic or computerized tomography examinations obtained. Careful neurologic examination for signs of cord trauma is necessary even if the radiographs are negative.

Abdominal injuries are generally due to solid organ damage, most frequently to the spleen or liver. Children tolerate intraperitoneal hemorrhage relatively well; many injuries requiring surgery in adults may be managed nonoperatively by experienced pediatric surgeons. The need to preserve the spleen to prevent subsequent overwhelming sepsis is also a consideration in management. Peritoneal lavage is, therefore, used much less frequently than in adults, with computerized tomography of the abdomen clearly accepted as the diagnostic procedure of choice.

Epidemiologic factors serve to alert the trauma physician to common injury patterns. This allows early recognition and treatment of typical injury syndromes and allows anticipation of atypical injuries or unusual complications.

Epidemiologic factors are also of importance in education and prevention. Pediatric trauma physicians should be aware of injury patterns and trends. Such appreciation is occasionally helpful in the individual case but, even more importantly, can be helpful in increasing trauma awareness in parents and society in general. Trauma physicians can play a valuable role in bringing more attention to bear on this important problem.

The psychosocial needs of pediatric trauma victims are of great importance. The child requires the support of the family unit, and parents are understandably anxious and upset. Trauma team management must address the issue from the time the child enters the emergency department until he leaves the hospital. The parents should be allowed to be as close to the child as possible and as soon as possible, as long as care is not compromised. A designated team member should be available to provide therapeutic updates and answer the questions of family members and friends. The child should receive appropriate explanations and reassurance provided in a calm and understandable manner. Emotional support during the acute phase is very important to achieving cooperation on the part of both the child and the family, family functioning and later emotional and physical rehabilitation of the child are also greatly influenced by their early emotional impressions.

Unfortunately, child abuse must always be a consideration in pediatric trauma. Whenever injuries are not consistent with the history provided, the emotional responses of child and family are atypical, or certain patterns of injury are present, abuse must be suspected. Failure to investigate this possibility frequently leads to more severe injury later. The issue should be addressed immediately and without hesitation. All emergency practitioners should be vigilant in this area, and every emergency department should have a defined protocol for dealing with suspected child abuse.

CONCLUSION

Trauma is a common and important problem in pediatric emergency care. An organized approach using general principles of trauma care with careful attention to anatomic, physiologic, psychological, and social factors unique to children can greatly improve eventual outcome. Pediatric emergency care providers must be able to deliver rapid, appropriate care for trauma victims.

REFERENCES

1. Barkin RM. Rosen P. Emergency Pediatrics. St Louis, MO: CV Mosby Co; 1987:506-315.

2. Tepas JJ 3rd, Ramenofsky ML, Molliti DL, Gans BM, DiScala C. The pediatric trauma score as a predictor of injury severity: an objective assessment. ) Trauma. 1988;28(4):425-429.

3. Kronick JB, Kissoon N, Frewen TC. Guidelines for stabilizing the condition of the critically ill or injured child before transfer to a tertiary care (acuity. Can Med Assoc 1. 1988;139(3):213-220.

4- Advanced Trauma Ufe Support instructor Manual Chicago, IL: American College of Surgeons; 1989.

5. Halpern JS. Mechanisms and patterns of trauma. Journal of Emergency Nursing. 1989;15(S):380-388.

6. Derlet RW, Silva J Jr, Holcroft J. Pedestrian accidents: adult and pediatric injuries J Emerg Med. 1989;7( 1 ):5-8.

7. Jacobs LM. The importance of airway management in trauma. J Noil Med Assoc. August 1988;80:873-879.

8. Handlet SD. Trauma to the larynx and upper trachea, Int Anesthesiol Clin. 1988;26(1):39.41.

9. Stembach GL, ed. Emergency airway management: methods to meet the challenge Topics m Emergency Medicine. 1988;10(l):31-43.

10. Kissoon N, Dreyer J. Walia M. Pediatric trauma: differences in pathophysiology, injury patterns, and treatment compared with adult trauma. Con Med Assoc J. 1990;142(l):27-34.

11. Eichelberger MR, Pratsch GL, eds. Pediatric Trauma Care. Rockville, MD: Aspen Publishers lnc; 1988:175-176.

12. Ramenofsky ML, Romenorsky MB, Jurkowvich GJ, Threadgill D, et al. The predictive validity of the Pediatric Trauma Score. ) Trauma. 1988;28(7):1038-1042.

13. RhodesM, AronsonJ, MoerkirkG, Petrash E. Quality of life after the trauma center. Trauma. 1988;28(7):931-938.

TABLE 1

Pediatrie Trauma Score

TABLE 2

The ABCs of Trauma

TABLE 3

Emergency Procedures Needed to Sustain Lite In Trauma Victims

TABLE 4

Resuscitation Phase Checklist

TABLE 5

Glasgow Coma Score

TABLE 6

Circumstances Likely to Require Transfer to a Pediatric Trauma Center

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