Epidemiology

The report of the Institute of Medicine’s Committee on Future of Emergency Care, released in June 2006, identified a lack of pediatric emergency services as a significant problem facing the health care system in the United States.¹ Trauma is the leading cause of death and disability in children and young adults.²

Pathophysiology

The anatomic characteristics of children predispose them to more significant injuries than adults would experience from similar trauma. The severity of pediatric head injury is related to the immature brain myelination, thin skulls, and larger head-to-body ratios in children. The bones and connective tissues of children are more pliable than those of adults, which can lead to potentially severe internal injuries with minimal external evidence of thoracoabdominal trauma. Because children have a greater ratio of surface area to volume, force can more easily be transferred to internal organs. Multiple trauma is common in children as a result of the smaller distance between vital structures. The sympathetic tone of a child is better than that of an adult, so a child’s blood pressure may be maintained despite large volume loss. Once a critical percentage of blood volume is lost (25%), a child’s blood pressure can drop precipitously, partly because of the inability of pediatric patients to change cardiac contractility and their dependence on the compensatory mechanisms of increased peripheral vascular resistance and heart rate. It should be noted that posttraumatic pediatric hypotension may also be an indicator of head injury rather than hemorrhage.³

Approach and Management

The ABCs of resuscitation (airway, breathing, circulation) should first be used to identify the loss of an airway or respiratory failure (or both). Direct injuries to the airway (oropharynx, trachea, or bronchi) are not the only cause of airway failure. An expanding neck hematoma or aspirated foreign body can have similar effects.

Breathing difficulty in children may be the sequelae of insults to the chest wall, lungs, heart, great vessels, or abdomen, as well as neurologic or muscular injuries. It may also result from the loss of ventilatory musculature, as with a cervical spine injury or respiratory muscle fatigue. Young children may have disordered ventilation secondary to gastric distention because considerable air is gulped into the stomach during crying.⁴

Circulation can be assessed in children through an evaluation of mental status, skin color and temperature, heart sounds, pulses, and capillary refill. Shock should be identified and treated immediately. Children differ from adults in several critical ways. The leading cause of cardiac arrest in children is hypoxemia. Normal blood pressure may be maintained in children sustaining trauma despite severe injury and massive blood loss (up to 25%). Shock in the setting of trauma should be presumed to be secondary to blood loss and be treated by restoration of volume. Two intravenous (or intraosseous) lines of the largest bore possible should be established immediately. Two boluses of crystalloid solution, 20 mL/kg each, should be administered. If shock persists, packed red blood cells should be transfused at 10 mL/kg and repeated as necessary. Other causes of shock, such as tension pneumothorax, pericardial tamponade, neurogenic shock, hypoxemia, metabolic derangements, and toxidromes, should be sought and treated concomitantly with restoration of volume.

Disability must be assessed thoroughly. Mental status is evaluated with the Glasgow Coma Scale (GCS) or an AVPU (alert, verbal, painful, unresponsive) scale (Table 23.1). An age-appropriate examination should be performed to evaluate for neurologic deficits.

Table 23.1 AVPU Scale

CATEGORY	APPROPRIATE RESPONSE	INAPPROPRIATE
Alert	Normal interaction for age	Lethargic, irritable
Verbal	Responds to name	Confused, unresponsive
Painful	Withdraws from pain	Nonpurposeful movement or sound without localization of pain
Unresponsive	No response to verbal or painful stimuli

Exposure of the body immediately after the ABCs have been addressed is imperative in all pediatric trauma patients. Emergency personnel should briefly expose and roll (with precautions) the patient to assess for initially unapparent injuries, such as a puncture wound in the posterior aspect of the chest in a victim of assault. Because of the increased ratio of surface area to volume in children and a propensity for hypothermia, blankets and warmed intravenous fluids should be used to maintain normothermia. Whenever feasible, family presence, which has been shown to not impede pediatric trauma resuscitation, should be accommodated during resuscitation to comfort the child.⁵ The emergency practitioner should communicate with the child during the examination.

After exposure, the secondary survey should be performed. An AMPLE history (allergies, medications, past medical history, last meal, and events leading up to the patient’s arrival in the ED) is obtained, followed by a complete head-to-toe examination. Particular attention should be paid to the eyes, ears, mouth, axillae, hands, and genitals. The utility of rectal examination has recently been called into question. In particular settings where questionable neurologic deficits are present or rectal or urogenital trauma is evident, a rectal examination may prove useful. It should be selective to avoid unnecessary emotional stress in the child.⁶ In an unconscious intubated patient, an orogastric or nasogastric tube and Foley catheter should be placed. As part of the secondary survey, initial radiographs and laboratory studies should be selectively ordered to further investigate any history and physical findings.

Priority Actions

A = Airway control—bag-valve-mask ventilation, endotracheal intubation

B = Breathing—maximize ventilation

C = Circulation—stabilize hemodynamic status

D = Disability—evaluate mental status and perform a neurologic examination

E = Exposure—completely undress and examine the patient

F = “Fingers and Foleys”—selective nasogastric or orogastric tube, bladder catheter, vaginal and rectal examinations

Secondary survey: Head-to-toe physical examination and AMPLE history (allergies, medications, past medical history, last meal, and events leading up to the patient’s arrival in the emergency department)

Laboratory studies and radiographs

Younger children, particularly infants, have little functional ventilatory reserve.⁷ Time is therefore of the essence in restoring oxygenation, ventilation, and circulation. The ABCs of resuscitation should be repeated if there is any change in the patient’s status.

The most common life- and limb-threatening injuries in children are those to the head, chest, and abdomen. In each of these areas, there are subtle but important clues to such injures (Box 23.1).

Box 23.1 Overview of Pediatric Trauma Management

Attend to the ABCs of resuscitation (airway, breathing, circulation) first. Connect the patient to a cardiac and oxygen saturation monitor; administer oxygen or secure the airway as needed.

Obtain intravenous or intraosseous access.

If the patient is hypotensive or tachycardic, administer normal saline in a 20-mL/kg bolus.

Roll the patient, perform a secondary survey, and recheck the vital signs.

If shock persists, additional intravenous access should be obtained (at least two large-bore intravenous lines), and a second 20-mL/kg bolus of normal saline should be administered.

Abdominal and thoracic ultrasonography, radiography, and laboratory studies should be performed as indicated.

If shock persists, transfuse packed red blood cells at 10 mL/kg, and continue evaluation for and treatment of life-threatening injuries.

Diagnostic Testing

Primary and Secondary Surveys

Primary and secondary surveys should be performed in children just as in adults. Particular modalities of testing are discussed in depth in later sections on specific systems and injuries. In a child with multiple trauma or severe injury, basic tests must be ordered as part of the primary and secondary surveys. Cardiac and oxygen saturation monitoring should be instituted. Plain radiographs of the cervical spine, chest, and pelvis should be obtained and reviewed immediately at the bedside. A bedside focused assessment with sonography for trauma (FAST) should be performed to evaluate for free fluid in the abdomen or pericardium. Laboratory studies include an immediate bedside glucose test, a complete blood count, serum chemistry analysis, coagulation studies, urinalysis, blood typing and cross-matching, blood gas measurements, and a pregnancy test. Further radiologic testing (e.g., computed tomography [CT], angiography, magnetic resonance imaging [MRI]), as well as more in-depth laboratory testing (e.g., hepatic function tests, screening for toxins or drugs, pancreatic enzyme measurements), may be ordered as indicated.

There are some pediatric-specific issues in the management of trauma. With younger patients, small tubes should be used for laboratory testing to avoid iatrogenic blood loss. The clinician should be aware that the hematocrit does not drop immediately in a child with acute blood loss before receiving isotonic volume resuscitation. For minimally injured patients, such as those with isolated extremity fractures or low-risk head or abdominal trauma, no laboratory studies are needed. In patients requiring an observation period, tracking the hematocrit or hemoglobin may be useful in combination with clinical reassessment. Toxidromes must be considered, especially in a patient with altered mental status, if the circumstances of the event are suspicious or when the patient is a teenager.

The ALARA (as low as reasonably achievable) principle should be applied to minimize exposure to radiation. The clinician should limit the number of CT scans performed and should make size-based adjustments to the radiation scanning parameters.⁸ Some investigators have questioned the need for portable radiographs of the cervical spine, chest, and pelvis to screen for injury in all trauma patients.⁴ As with trauma triage, it is advisable to err on the side of caution. These studies should be performed in all seriously injured patients or if the status of the spine, chest, or pelvis is at all uncertain. A more focal radiologic screening examination, as indicated by the history and findings on physical examination, may be considered in stable patients with normal mental status. Children younger than 2 years in whom child abuse is suspected must undergo a skeletal radiographic survey to diagnose occult or remote injuries.

Documentation