1 What is the importance of trauma to the health of children?

Injury is the leading cause of death in children older than 1 year (Fig. 58-1). Although injury death rates in the U.S. population have declined since 1991 (except for 2001 because of September 11), trauma is still the number one killer of children. Most injury is responsible for intermediate morbidity, with significant impact on the functioning of children and their progress to adulthood. Trauma is responsible for about 22,000 deaths per year in children age 19 years and younger. The number of permanently disabled may approach over 100,000 per year. Hospital admissions in the 0–14 age group for trauma is estimated to exceed 250,000 per year (> 51/100,000 population).

Figure 58-1 Iceberg of pediatric injuries—the American College of Surgeons Advanced Trauma Life Support guidelines, 1999.

Peclet MH, Newman KD, Eichelberger MR, et al: Patterns of injury in children. J Pediatr Surg 25:85–91, 1990.

Centers for Disease Control and Prevention: National Vital Statistics Report. Deaths: Preliminary data for 2002: www.cdc.gov/nchs/data/nvsr/nvsr53/nvsr53_15.pdf

Centers for Disease Control and Prevention, National Center for Health Statistics. National trends in injury hospitalizations: 1971–2001: www.cdc.gov/nchs/data/injury/InjuryChartbook79–01.pdf

2 What specific mechanisms of injury are seen typically in children?

Centers for Disease Control and Prevention: Web-based Injury Statistics Query and Reporting System: www.cdc.gov/ncipc/wisqars/

3 Discuss the importance of sports-related injuries

Sports-related injuries are common but do not often lead to death. Neck injury due to falls from equestrian sports or football spearing is an important cause of severe injury and death despite a fairly low incidence. Blunt trauma from sports can lead to serious head, intra-abdominal solid-organ, and eye injury. In terms of visits for emergency care, sports injuries are responsible for large numbers of musculoskeletal injuries, fractures, and joint injuries.

4 Describe the prehospital care capability for children with potentially serious injuries

Emergency medical technicians have a great deal of adult experience in advanced life support, which transfers to older children and adolescents. Important skills, such as endotracheal intubation and IV access, can be more of an issue in younger patients. Early studies reported successful field intubation rates of 50% in infants < 1 year of age and 64% in children < 18 years of age. Rates of success with IV access have been fair in infants, good in preschoolers, and excellent in adolescents. Even with programs conducted to improve these rates (such as procedures in the operating room and field courses), in settings with less experienced providers and short transit distances, the best procedure is safe extrication/preparation and immediate transfer to the hospital.

Gausche M, Lewis RJ, Stratton SJ, et al: Effect of out of hospital endotracheal intubation on survival and neurological outcome. JAMA 283:783–790, 2000.

Losek JD, Szewczuga D, Glauser PW: Improved prehospital pediatric ALS care after an EMT-paramedic clinical training course. Am J Emerg Med 12:429–432, 1994.

5 Describe the initial approach to children with potentially serious injuries

The ABCDEs are used during the primary assessment to define underlying injury and to reverse potential life-threatening problems:

The team must assess and stabilize each step in order (i.e., control of airway always precedes control of circulation).

6 How can one appropriately “clear the cervical spine” in a trauma patient?

In the alert patient with no distracting injury and no midline cervical pain with palpation, the patient can be cleared clinically by assessing active range of motion. Anteroposterior, lateral, and odontoid radiographs of the cervical spine should be obtained and proper immobilization should be continued if the cervical spine is tender to palpation, if the patient has altered mental status or neurologic deficits (even the presence or history of numbness, tingling sensation, decreased sensory, or motor function), or if a distracting injury exists (such as an extremity fracture or abdominal pain).

Slack SE, Clancy MJ: Clearing the cervical spine of paediatric trauma patients. Emerg Med J 21:185–189, 2004.

7 Is hypertonic saline beneficial in the fluid resuscitation of the multiply injured trauma patient with severe head injury?

Studies performed in pediatric and adult trauma patients in the intensive care unit setting have demonstrated the safety and efficacy of hypertonic saline for acutely decreasing intracranial pressure compared to traditional therapies. The proposed mechanism for use of hypertonic solutions is that increased serum osmolality decreases intracranial pressure via the osmotic pressure gradient. Initial fluid resuscitation with hypertonic saline may therefore be helpful in supporting blood pressure as well as decreasing intracranial pressure in this patient population.

Simma B, Burger R, Falk M, et al: A prospective, randomized, and controlled study of fluid management in children with severe head injury: Lactated Ringers solution versus hypertonic saline. Crit Care Med 26:1265–1270, 1998.

8 Explain the secondary survey

It is the detailed head-to-toe physical examination that follows the initial ABCDE survey and resuscitation. The head, neck, and face are surveyed first for evidence of blood or occult injury with control of the cervical spine. Assessment of maxillary and mandibular stability, eyes, ears, and oropharynx follows. Careful assessment of the bony thorax, lungs, and cardiovascular system are next, followed by assessment of the abdomen, pelvis, and external genitourinary tract. The child should be logrolled in a neutral position to assess the back, posterior chest, and spine. Lastly, the extremities are assessed carefully for obvious and occult injury, along with neurovascular status. Observers may integrate evaluation of the central nervous system during each part of the examination or perform the entire central nervous system evaluation at the end.