Pediatric trauma is a leading cause of morbidity, mortality, and disability for children. More than 9143 children died in the United States due to trauma-related injuries in 2010.¹ For each childhood death associated with injury, more than 1000 children received medical attention for nonfatal injuries.² According to the American College of Surgeons National Databank 2013 Pediatric Report, 152,884 patients younger than 19 years of age were admitted to 803 facilities across the United States and Canada with 2834 fatalities. Trauma is the leading cause of death in children over age 1 and exceeds all other causes of death combined.³

Unintentional injury death rates are high in some subgroups including newborns and infants less than 1 year of age and teenagers age 15 to 19 years old.⁴ Gun-related injuries in this population lead to 8.87 hospitalizations per 100,000 persons <20 years of age in 2009, with 6.1% dying in the hospital (35.1% fatality from suicide).⁵ In 2010, gun-related injuries accounted for 6570 deaths of children and young people (1 to 24 years of age).⁶

BEHAVIORAL CONSIDERATIONS

In general, a child’s developmental stage dictates the expected behavioral response to injury. An infant should be appropriately curious and interactive or afraid of strangers, while an older child should respond with fear to invasive procedures. Understanding normal child development helps identify alterations of the sensorium, which may be the result of traumatic brain injury, hypoperfusion, or hypoxemia.

Family presence during trauma care is extremely important, not only to help assess the child’s mental status, but also to support the injured child. Studies repeatedly demonstrate that parental presence is beneficial for both the patient’s and parent’s psychological well-being, does not interfere with medical efforts or increase stress in the healthcare team for the most part, and does not result in increased medicolegal issues. Family presence during resuscitation is an important standard practice in pediatric care.^7,8,9

ED PREPAREDNESS

Children require age- and size-based medication and equipment, so EDs should prepare an appropriate pediatric resuscitation area, provide personnel with adequate training in the care of children, and stock appropriately sized pediatric resuscitation equipment.¹⁰ In 2013, the American Academy of Pediatrics, the American College of Emergency Physicians, the Emergency Nurses Association, and the Emergency Medical Services for Children developed the Pediatric Readiness Project¹¹ to improve care for children in the ED, to provide a quality improvement process following the Guidelines for Care of Children in the Emergency Department,¹² and to measure ED improvements over time. Approximately 5000 EDs with a response rate of over 80% were involved, resulting in one of the most successful assessments to date.¹³

The pediatric head has a larger surface area that is prone to significant bleeding either from open scalp wounds with brisk arterial bleeding or in the form of cephalohematomas or subgaleal hematomas that can cause hypovolemic shock in small infants. The cranium is thinner, transmits energy easily, and predisposes to skull fractures.¹⁴ Open sutures in infants can accommodate increases in intracranial pressure and delay the recognition of serious intracranial injuries. Infants have prominent extra-axial intracranial spaces through which bridging cortical vessels traverse and are prone to sheer and acceleration-deceleration forces such as those sustained in aggressive shaking; this accounts for classic findings such as subdural hemorrhages in inflicted injury victims.¹⁵ Finally, the size of the head in young children is larger compared to the body, which predisposes to closed head injury when children fall and will also occlude the airway when placed supine without back support.

The facets in the pediatric cervical spine are more horizontal than in adults, with less calcified vertebral bodies, increased laxity of spinal ligaments, and weaker supporting musculature, all of which allow translational forces to cause spine injuries without bony abnormalities. Due to the weaker neck musculature and larger cranium, the fulcrum of force is more cephalad, predisposing children to higher cervical spine injuries compared to adults (see chapter 139, “Cervical Spine Injury in Infants and Children”).^16,17

Significant anatomic differences between pediatric and adult airways are discussed in chapter 111, “Intubation and Ventilation in Infants and Children,” as they relate to advanced airway management. The pediatric laryngeal cartilages are more pliable and therefore less prone to fracture than the firm ossified adult cartilages.^18,19 Although the larynx is relatively protected, children have higher risk for airway compromise due to soft tissue swelling or expanding hematoma in relation to the smaller size of the pediatric airway and neck.

The chest wall in children is more compliant, its tracheobronchial structures are more vulnerable, and the heart is more anterior with mobile mediastinal structures, all of which predispose to intrathoracic injury such as pulmonary contusions with minimal thoracic wall injury. Delicate tracheobronchial structures are susceptible to barotrauma especially in situations of excessive volume ventilations during resuscitation generating iatrogenic pneumothorax. The diameter of the respiratory structures is much smaller than adults, and a change in the inner diameter (from aspirated fluids or secretions) has a four-fold impact on the resistance to air flow as stated by the Hagen-Poiseuille equation, predisposing to airway obstruction.

The child’s abdomen is relatively larger in size compared with the rest of the trunk, has underdeveloped musculature, and has relatively larger size intra-abdominal organs, which predisposes to solid organ injuries in blunt abdominal trauma and hollow viscus injuries in certain acceleration-deceleration mechanisms such as seat belt injuries.

The skeleton is incompletely calcified, which renders bones more pliable and leads to bowing and greenstick injuries; multiple active growth centers and weaker epiphysis explain certain fracture types specific to children such as supracondylar fractures of the elbow and epiphyseal injuries such as the ones described by the Salter-Harris classification (see chapter 140, “Musculoskeletal Disorders in Children”).²⁰

The higher body surface area to overall body mass in children and thin epidermal and dermal layers of the skin along with a paucity of subcutaneous fat and immature thermoregulatory mechanisms lead to increased propensity for hypothermia in cold environments which must be considered when assessing an exposed child in the trauma bay.²¹

Table 110-1 shows the expected vital signs according to age. Be alert to abnormalities in heart rate, respiratory rate, and peripheral perfusion that can indicate acute deterioration in the setting of trauma.²²

Cardiac output is mediated primarily by heart rate in children as opposed to stroke volume in adults. Children with significant blood loss develop tachycardia, which can be sustained for a variable period of time before cardiac output is compromised. In addition, the vasculature is quite sensitive to endogenous catecholamines, allowing children to modify vascular tone in response to hemodynamic changes and regulate perfusion to the core organs. These two parameters, capacity to increase heart rate and modulate peripheral vascular resistance, help children maintain normal blood and perfusion pressures in the face of significant hemorrhage (25% to 30%), and hypotension is a very late and ominous sign of cardiovascular compromise in children.²³

In children, pulmonary tidal volume is relatively fixed, so minute ventilation is maintained primarily by respiratory rate (tachypnea) rather than depth (hyperpnea). Small residual volumes contribute to atelectasis, and a smaller functional residual capacity contributes to rapid desaturation during apnea.²⁴

Finally, the metabolic demands in children are higher than adults. Children have a much higher energy expenditure and caloric requirement at baseline. Although stress-induced hyperglycemia is common in the setting of polytrauma, hypoglycemia can occur and should be treated promptly.

AIRWAY

The most important step in trauma care for children is assessment and stabilization of the airway. Children experience desaturation sooner than adults, and desaturation is quickly followed by respiratory arrest, which can lead to full cardiac arrest. For this reason, the most experienced clinician should be in charge of airway management.

Assess the patency of the airway first; note a hoarse or muffled cry or voice, stridor or sonorous respirations, increased work of breathing, or poor chest rise with bag-valve mask ventilation. Evaluate the maintainability of a protected airway in the presence of facial or neck trauma or facial burns, or in patients with neurologic compromise that precludes them from having an organized breathing pattern.

Perform basic airway maneuvers such as jaw thrust and oropharyngeal suctioning and maintain a sniffing position to align the airway axes, often by placing a towel roll under the shoulders. Consider use of airway adjuncts such as nasal trumpets, oral airways, or supraglottic devices until a definitive airway through endotracheal intubation can be achieved (see chapter 111).

Maintain in-line cervical spine stabilization at all times. Rapid sequence intubation is the safest method of intubating a trauma patient with a full stomach. When possible, limit positive-pressure ventilation before intubation to avoid gastric insufflation and vomiting. Indications for endotracheal intubation in the trauma patient include:

1. 
   

   Glasgow coma score <8 or inability to maintain or protect the airway

   
   
2. 
   

   Inadequate oxygenation or ventilation

   
   
3. 
   

   Inability to ventilate or oxygenate with bag-valve mask

   
   
4. 
   

   Potential for clinical deterioration (e.g., facial burns, inhalation injury)

   
   
5. 
   

   Flail chest

   
   
6. 
   

   Decompensated shock resistant to fluid resuscitation

   
   
7. 
   

   Anticipated surgical intervention or need for radiologic investigation outside of the ED in an unstable patient

BREATHING

Assess the adequacy of breathing, ventilation, and oxygenation through careful observation of the rate, depth, pattern, and work of breathing, including tracheal position and symmetry of chest wall rise and fall. Note that alterations in the mental status might signify hypoxia (agitation) or hypercarbia (somnolence) from inadequate breathing.

Remember that small children are predominantly diaphragmatic breathers, are highly sensitive to increased intra-abdominal pressure, and have mobile mediastinal structures that predispose to pneumothorax, hemothorax, or flail chest that can rapidly compromise respiration and ventilation.

When there is concern for tension pneumothorax, perform needle thoracostomy by placing a 14- to 18-gauge IV catheter in the midclavicular line at the second intercostal space attached via a three-way stopcock to a 10- to 20-mL syringe; do not wait for radiologic confirmation in the hemodynamically unstable child.

CIRCULATION

Recognize early signs of circulatory shock including tachycardia, mental status, and color and perfusion abnormalities, because hypotension is typically a terminal event in children. Estimate normal systolic blood pressure in children 1 to 10 years of age using the following formula: 90 + (2 × age) mm Hg; hypotension can be estimated as systolic blood pressure less than 70 + (2 × age) mm Hg.²⁵

Evaluate the heart rate, peripheral pulses, capillary refill time, skin color, body temperature, and mental status, which is an important surrogate for perfusion. Control external hemorrhage by applying direct pressure to limit ongoing blood loss; perform additional maneuvers such as scalp suturing, fracture reduction, and pelvic binding to limit ongoing hemorrhage.

Vascular access can be challenging in small children and is more difficult in shock. Ideally, place two proximal large-bore IV catheters, but limit attempts in the unstable child and proceed to intraosseous access if unsuccessful after 90 seconds (see chapter 112, “Intravenous and Intraosseous Access in Infants and Children”).

For compensated or uncompensated shock, give a rapid infusion of crystalloid (20 mL/kg of normal saline or lactated Ringer’s solution). Give two to three boluses rapidly as needed, ideally within 5 minutes each using an automated “rapid infuser,” a frequently monitored pressure bag, or the “hand push and pull method.”²⁶ After two to three crystalloid boluses, consider 10 mL/kg boluses of warmed O-negative blood.

Although techniques such as permissive hypotension and “damage control resuscitation” with goals to limit hemorrhage, hemodilution, and the disruption of the clotting process have been widely studied and practiced in adult trauma care,²⁷ there are insufficient data to recommend routine use in pediatric trauma patients. Children may tolerate relative hypotensive states better than adults, but the current standard of care is to maintain tissue perfusion with crystalloid boluses and blood component replacement until definitive surgical control of hemorrhage is achieved.¹⁰

Pediatric rapid or massive transfusion protocols, on the other hand, have been widely studied and used in pediatric trauma centers. Implement a massive transfusion protocol, if available, when the need for transfusion is anticipated to equal one or more blood volumes within a 24-hour time frame or half of a blood volume in 12 hours is suspected. Massive transfusion protocols replace red blood cells, plasma, and platelets in specific amounts (usually 1:1:1) with the goal of minimizing the coagulopathy associated with significant hemorrhage and minimizing the effects of hypothermia and acidosis.²⁸

DISABILITY

Assess mental status and neurologic deficits as part of the primary survey. Mental status can be assessed using the modified pediatric Glasgow coma scale, which mirrors the familiar adult Glasgow coma scale in assigning points for eye opening and motor response using the same scale, but defines verbal response in an age-appropriate way (Table 110-2).

However, the Glasgow coma scale lacks good interobserver reliability and reproducibility and does not accurately predict outcomes in individual patients.²⁹ A simpler and validated method to assess mental status in children is by using the AVPU score, which is currently recommended by the pediatric advanced life support guidelines²⁵ (Table 110-3).

In addition to assessing mental status, perform a pupillary examination and focused assessment of tone and strength.

EXPOSURE

To identify all potential injuries and perform life-saving procedures, disrobe and expose the child; however, children are particularly susceptible to hypothermia when exposed to cold environments or receiving room temperature fluids.³⁰ To avoid iatrogenic hypothermia, maintain a warm resuscitation environment, remove wet clothing, and place warm blankets underneath the child. Additional measures to maintain euthermia include use of radiant warmers and infusion of warmed intravenous fluids. Monitor and record temperature carefully throughout assessment and resuscitation.

Begin the secondary survey after the primary survey is complete and resuscitative measures have been initiated. For the secondary survey, perform a complete head-to-toe physical examination, cervical spine evaluation, and clearance. Ancillary tools such as pulse oximetry, blood gas measurement, and quantitative end-tidal carbon dioxide (CO₂) monitoring help guide therapy. Initiate laboratory evaluation, bedside ultrasonography, and radiographic imaging. During the secondary survey, perform nonemergent procedures such as placing a nasogastric or orogastric tube and Foley catheter (minimum urine output should be 0.5 mL/kg/h). A nasogastric tube will decompress the stomach, as a full stomach can restrict functional residual capacity.

In this phase, stabilize the child’s condition sufficiently to allow transfer to the radiology suite or inpatient unit or a facility that can provide a higher level of care. Reassess the airway, breathing, circulation, and neurologic status continually because some injuries may manifest over time and complications from therapeutic interventions can occur. Consider endotracheal tube dislodgment, equipment failure, pneumothorax, regurgitation and aspiration of stomach contents, occult hemorrhage, and progression of intracranial hypertension as causes for deterioration. Carefully monitor fluid administration to prevent inadvertent overhydration. Provide appropriate analgesics and sedatives because pain treatment is often neglected in children.

REFERRAL TO A PEDIATRIC CENTER

Pediatric trauma center designation in the United States is conferred by governmental authority, and requirements vary from state to state. Guidelines have been created by American College of Emergency Physicians and American College of Surgeons to delineate the capabilities of a pediatric trauma center.¹⁸ The receiving institution should have a dedicated pediatric trauma service; comprehensive pediatric services should be available from scene care to rehabilitation and reintegration into the family and society. The trauma team should be immediately available at all times and capable of treating at least two patients simultaneously. Additional pediatric specialists should be on site or immediately available, including specialists in pediatric emergency medicine, anesthesiology, neurosurgery, radiology, orthopedics, critical care, and nursing. A pediatric intensive care unit is an essential component of a designated pediatric trauma center.

Use of trauma triage scores can help identify a child with more severe injuries, increase awareness of the need for higher level of care and monitoring, and predict outcomes. Two of the most commonly used systems are the Pediatric Trauma Score (Table 110-4) and the Revised Trauma Score (Table 110-5). Their advantages over other systems include use of physiologic variables instead of reliance solely on anatomic factors. Lower scores are associated with greater mortality and thus a need for pediatric trauma center care: a Revised Trauma Score of <12 or a Pediatric Trauma Score of <8 should prompt transfer to a pediatric trauma center.³¹

Additional indications for transfer to a pediatric trauma center are listed in Table 110-6.³² Anatomic and physiologic parameters are most useful in determining which children should be transported to a trauma center.

Care of seriously injured children at a pediatric trauma center is associated with improved survival. In a study of 53,702 pediatric traumas comparing children treated at adult or pediatric trauma centers, the adjusted odds of mortality was 20% lower for children seen at trauma centers with pediatric qualifications.³³ If not available, transport to a designated trauma center, adult or pediatric, is still associated with improved outcomes.^34,35 Interfacility transfer of critically injured children is best done by a specialized pediatric transport team or a critical care transport team with pediatric experience when available (see chapter 107, “Neonatal and Pediatric Transport”).

GENERAL ASSESSMENT

The goals of evaluation in a trauma victim are to determine the extent and severity of injury, what interventions, if any, are needed, and the level of monitoring required if admission is indicated. The mechanism of injury, history, and initial physical examination influence the degree of suspicion for intra-abdominal injury and guide subsequent radiographic and laboratory evaluation. Persistent emesis (especially bilious or bloody), abdominal distention, abdominal pain or any signs of peritoneal irritation, gross hematuria, and blood on rectal examination are indications for further investigation.

Carefully inspect the abdomen for signs of trauma including distention, abrasions, seat belt marks, or ecchymosis. Palpate for abdominal tenderness, which has a has a high positive predictive value for intra-abdominal injury. In high-mechanism injuries, maintain a high index of suspicion because pancreatic and hollow viscus injuries can present with delayed symptoms such as pain or emesis. Clinical evaluation of patients with altered mental status or distracting or associated injuries is difficult, and in this setting, a normal abdominal examination does not rule out the possibility of injury.

LABORATORY INVESTIGATION

Routine laboratory “trauma panels” are frequently obtained in the evaluation of injured children, but individual laboratory abnormalities, while common, are seldom useful to dictate therapy, and no single laboratory test has acceptable sensitivity or negative predictive value to safely and effectively screen patients with abdominal trauma when used alone.³⁶ Even organ-specific chemistries predicted injury poorly in children, are of little value, and alter acute management in only 5% to 6% of trauma patients.³⁷ Although elevated liver function tests, particularly alanine aminotransferase, are suggestive of liver injury, no consensus exists as to the cut point for determining risk. Alanine aminotransferase levels >80 to 125 units/L have a sensitivity of 77%, specificity of 82%, but a positive predictive value of only 16%.^38,39 An exception to the generally poor utility of liver function tests is in the setting of suspected inflicted injury in infants and young children, for whom liver function tests are recommended as a screening tool to detect occult blunt intra-abdominal injury.⁴⁰