Prevalence

Overall, trauma is the number three cause of mortality (6%) and serious morbidity throughout life. However, trauma is the number one cause of death and disability between the ages of 1 and 44. Therefore it is the prime cause of death and serious injury throughout childhood – rendering it the most important health issue in children and adolescents. In most Western societies road trauma contributes about half (50%) of all serious injuries and deaths, with drowning incidents contributing up to 25%. The third major cause is burns and the remainder includes a range of miscellaneous causes. In most series, child abuse contributes less than 10% of all child deaths.

This chapter concentrates on those aspects of trauma management that are different in children. Overall, paediatric surgeons and paediatricians have taken a holistic view of trauma and have been heavily involved in aspects of prevention, immediate treatment and rehabilitation.

Prevention

Over the last decades, Australia has done well in reducing the death rate from approximately 11.5 deaths per hundred thousand to about 8.5 (World Health Organization).¹ However, while the death rate has been almost halved, it is still double that of some of the best OECD countries. Most developed countries have significantly reduced injury death rates. Unfortunately this is not the case in developing countries. While we have achieved much through prevention strategies, there is still more to be done.

Prevention has involved the work of legislators (seat belts, baby capsules, cycle helmets) through to educators and implementation groups such as ‘Kidsafe’. Generally the community has been supportive of the minor inconveniences that accompany improvements in child safety.

Future progress will depend on campaigns refreshing the messages, as every few years there is a new generation of young parents and it cannot be assumed that a good campaign 3 to 5 years previously will suffice. There needs to be ongoing activity. We also need to be aware that we are promoting healthy, safe activities. This does not equate to safety above all other considerations. Our children should not be sitting in front of televisions and computer games and never going outside because that is perceived as being dangerous. Rather, through appropriate research we should further identify problem areas that are key factors in the causation of road trauma, drowning, house fires, serious falls and sporting injuries. Our children should be safely riding their cycles rather than believing that cycling is unsafe. This will require much more work by all levels of community as individuals, councils and governments. We do need to take account of children’s needs for activity in homes, playgrounds, skateboard areas, walkways and cycle paths in order to plan prevention strategies.

Succinct treatment (salvage)

The advent of trauma teams and trauma systems in hospitals that receive paediatric patients has led to great improvements in paediatric injury care. It is estimated that there may have been a 20% decrease in mortality as a result of these systems. However, it is prevention that has resulted in most of the improvement in mortality.

Hospitals now have trauma teams ready to receive the child. This may occur by forward notification by the emergency management services. Trauma team activation should occur on notification when a child is at high risk of life-threatening injury according to prediction by pre-determined clinical and mechanism parameters (Table 3.1.1).

MVA, motor vehicle accident.

Source: Adapted from Cameron P. 2004. Textbook of Adult Emergency Medicine, 2nd edn.

The trauma team should include a team leader, airway doctor, procedure doctor, and nursing staff from within the emergency department. Activation may involve alerting appropriate colleagues from radiology, anaesthetics, intensive care and surgical specialties according to local resources and protocols, in order to expedite emergent care. The activation process needs to be adapted to the varying local resources of the individual department, which vary between institutions.

Regular trauma meetings to review cases or videotape evaluation of resuscitation can provide education, with lessons learnt on ‘how to do things better’. As major paediatric trauma is relatively uncommon, mock paediatric resuscitation scenarios can provide the emergency department staff with an opportunity to improve preparedness. There is now a good body of international literature available to keep the trauma team up to date with the optimal care of paediatric trauma patients. The use of a trauma proforma sheet may be useful for the documentation of the assessment and resuscitation of children with major injuries (see Table 3.1.1).

Clinicians often worry about managing children with major trauma and wonder how much they should treat them as adults and how much they should take note of their differences. In adults it is well established that the A, B, C, D, E primary survey approach is the correct paradigm. In managing paediatric trauma clinicians sometimes get confused. They have a vague memory that ‘children are different’. They are not sure therefore whether to clearly follow the A, B, C, D, E or a different approach.

The best way to remember the acute management of trauma in children is to remember the a, b, c, d, e as lower case. That is, the sequence is exactly the same as in adults but there are additional nuances in children to optimise their care. However, more children suffer or die in the acute management of trauma by clinicians panicking and not following the A, B, C, D, E approach rather than doctors not being completely familiar with these nuances (see primary survey below). Delayed management of airway obstruction or inadequate fluid management are the two most common contributors to preventable paediatric deaths in trauma. Chapters 2.2 and 2.3 provide a detailed discussion of basic life support and advanced life support (ALS) techniques in children applicable in trauma.

The worst response is to panic and freeze. In this situation a child may be left un-intubated, whereas in an adult patient intubation would be performed as a reflex decision. A child with a Glasgow Coma Scale (GCS) of less than 8 should not be left with face mask oxygen; in an adult there would be rapid intubation. Similarly, intravenous lines can be difficult to insert in the shocked paediatric patient, and children may receive delayed fluid resuscitation if intraosseous access is not considered as an alternative where indicated. The supportive management of the child’s family is a further important consideration in the emergency setting.

Primary survey

The initial assessment of the seriously injured child should follow a structured approach so that life-threatening problems are rapidly identified and managed in the appropriate rapid sequence. This approach is based on the prioritised principles as outlined in the teaching dictums of courses such as the Advanced Paediatric Life Support (APLS) and Advanced Trauma Life Support (ATLS) groups, which are invaluable for practitioners who deal with paediatric trauma.

The approach includes initially the primary survey with securing of (A) airway, (B) breathing and (C) circulation, and immediate management of threats to life. The stabilisation of the cervical spine occurs concurrently with airway management. Following this rapid initial stabilisation, a brief neurological assessment of the child should occur (D) with complete exposure for otherwise occult signs of injury and a prompt to consider environmental issues such as hypothermia (E).

In the team approach, the management should ‘occur horizontally’, with simultaneous attention to these priorities by designated members of the team, overseen by the team leader. The role of the primary survey is therefore to detect and treat abnormal physiology immediately in order to prevent potential secondary insults due to hypoxia or hypovolaemia. A secondary survey follows with a head to toe, front and back examination of the child.