Trauma is the forceful disruption of bodily homeostasis and is the leading cause of death in children and young adults in developed countries (Fig. 30.1). It comprises unintentional as well as intentional injuries, including child abuse. Approximately half of all injuries to children involve multiple organs or body regions, and these injuries are associated with a higher casebased fatality rate. Blunt injury is far more common than penetrating injury in children, although the latter is more deadly (Table 30.1). During the last three decades in the United States, the population-based mortality rate for unintentional pediatric injury has fallen by more than 50%, although it remains the most common cause of death for all pediatric patients in the most recent year for which statistics are available (2009) (1), followed in older adolescents by homicide and suicide. Indeed, although mortality rates for the leading causes of pediatric death have declined in developed countries, the decline is least for trauma (Fig. 30.2). Most pediatric deaths from trauma are associated with motor vehicles and occur prior to hospital admission. The morbidity of pediatric trauma increases with increasing severity of injury and is manifested frequently by functional limitations following major injury; the overall cost is difficult to estimate, although it is likely enormous.

Trauma remains the “neglected disease of modern society,” as it was originally described in a monograph by the National Academy of Sciences over 40 years ago (2). Organizing a community for pediatric trauma care requires not only specialized knowledge of the evaluation and management of childhood injury, but also the ability to ensure that the special needs of children are met throughout the entire continuum of trauma care—from prevention, through prehospital care, transport, emergency care, operative and intensive care, recovery, and rehabilitation. Reductions in the rates of pediatric trauma morbidity and mortality are the result of concerted efforts during the last few decades, which have involved research, education,
legislation, and an investment in medical services at all levels. Further declines in pediatric trauma morbidity and mortality in the United States will require an even broader and more vigorous public health approach, probably modeled after some of the more successful systems in European countries such as Sweden, Italy, the UK, and the Netherlands.

Injuries are, for the most part, not true “accidents,” but predictable events rooted in a complex web of social, cultural, and economic factors that impact upon the host, agent, and environment. Injury rates have been shown to respond to established harm-reduction strategies based within the community. The National Safe Kids Campaign (www.safekids.org) and the Injury Free Coalition for Kids (www.injuryfree.org) have both proven effective in reducing the burden of childhood injury (3). Comorbidities common to many injured children and adolescents include limited access to health care, altered family dynamics (including child abuse), increased risk-taking behavior (including substance abuse and intoxications), and suicidal intent, among others. Strategies to limit such comorbidities are likely to prove useful in reducing childhood injuries.

Intracranial injuries are the cause of most pediatric trauma deaths (due at least in part to the untoward effects of traumatic coma on airway patency, breathing control, cerebral perfusion, and to the pediatric anatomy). The evaluation and management of neurologic injuries is reviewed elsewhere in Chapter 61. Most blunt trauma in childhood is unintentional, but 7% of serious injuries are due to intentional physical assault (of which nearly half, or 3%, are due to child abuse) (4). Blunt injuries outnumber penetrating injuries in children by a ratio of 12:1, a ratio that has decreased in recent years. While blunt injuries are more common, penetrating injuries are more lethal.

Injury mechanism is the main predictor of injury pattern (Table 30.2). Pedestrian motor vehicle trauma may result in the Waddell triad of injuries to the head, torso, and lower extremities, while occupant injuries include head, face, and neck trauma in unrestrained passengers, and cervical spine injuries, bowel disruption or hematoma, and Chance fractures of the spine in restrained passengers. Bicycle trauma results in head injury in unhelmeted riders and upper extremity and upper abdominal injuries (results from contact with the handlebar). Low falls, the most common cause of childhood injury, rarely produce significant trauma, but high falls (from the second story or higher) are associated with serious head injuries, with the addition of long-bone fractures (at the third story), and intrathoracic and intra-abdominal injuries (at the fifth story, the height from which 50% of children can be expected to die) (5). With the growing popularity of extreme sports (including extreme skiing and surfing, inline skating, mountain bicycling, rock climbing, skateboarding, snowboarding, and ultraendurance racing) in which risk is very high and often underappreciated, patterns of adolescent traumatic injury are likely to change.

While it is important to realize that the involvement of multiple organ systems is typical following major trauma in children (due chiefly to their small size, the proportionately larger size of the head, and the proportionately smaller size of the torso), major pediatric blunt trauma is more a disease of airway and breathing than of bleeding and shock.

Though uncommon in most pediatric trauma, hemorrhagic shock remains an important problem in major trauma, and advances have come from recent experience in the battlefield. We will review research, which suggests improved outcome
from severe military trauma via better control of hemorrhage achieved by the application of tourniquets following traumatic amputation as well as vigorous replacement of coagulation factors. Application of experience from battlefield resuscitation is likely to help improve outcome for civilian trauma.