Trauma is the chief cause of mortality and morbidity in children in the United States. Although general principles of trauma treatment are common to children and adults, there are specific developmentally-based considerations that make pediatric trauma special. Flexibility, pragmatism, as well as urgency are called for in this setting.

      I.   Epidemiology of pediatric trauma (1)

               A.   Age and sex are the most important factors influencing the patterns of injury.

                       1.   In the infant and toddler age group, falls are a common cause of severe injury (25% in the age group 0 to 9 years), whereas bicycle-related mishaps, with or without concurrent motor-vehicle injury, are the principal cause of injury in older children and adolescents.

                       2.   For children aged 0 to 2 years, falls from furniture, beds, and parents’ arms were most common, while for children aged 3 to 9 years, falls from playground equipment were most frequent (2).

                       3.   Most pediatric trauma occurs as a result of blunt trauma, with penetrating injury accounting for 10% to 20% of pediatric trauma admissions (7.5% for all children; 12.7% for ages 13 to 18 years, and rising sharply after age 13 years).

                       4.   Tracy et al analyzed 354,196 pediatric trauma patients with the leading mechanisms of injury as motor-vehicle collisions for ages 10 to 18 years and falls for ages 0 to 9 years.

                       5.   Fire was the second leading cause among 1-year-olds, but not a major cause in other age groups. Penetrating trauma was the mechanism of injury for 21% of adolescents with public or no insurance versus 7.5% adolescents with private insurance. Injury severity scores were the highest for children less than 1 year and 14 to 18 years old (2).

               B.   Because blunt trauma is the most common (3–5), it will often require diagnostic examination of a sedated or anesthetized child prior to definitive care or even identification of the underlying problem. For this reason, the anesthesiologist is often administering an anesthetic in the setting of an uncertain diagnosis, not at all similar to routine anesthetic practice.

               C.   The crucial skills of the anesthesiologist in this setting are amplified as a monitor of evolving situations, particularly in circumstances when an occult injury may become unstable and require rapid intervention in the ICU or the operating room.

                       1.   Outcome prediction in the context of this uncertainty is often helpful, and several scoring systems have evolved beginning with the Injury Severity Score (ISS) (6) and more recently the Trauma Mortality Prediction Model (TMPM-ICD-9) (7).

                       2.   The central nervous system is the most commonly injured body system (1,8,9), but more than 86% of children will have a Glasgow Coma Score (GCS) greater than 12 (7).

               D.   In children aged 2 years or younger, physical abuse is the most common cause of serious head injury.

                       1.   Shaken baby syndrome offers few signs of external trauma but is highly suspect when accompanied by retinal hemorrhage and subdural or subarachnoid hemorrhage.

               E.   In children aged 3 years and older, falls and motor vehicle, bicycle, and pedestrian accidents are responsible for most traumatic brain injuries.

                       1.   The GCS is the universal tool for the rapid assessment of the consciousness level of injured children and is a significant predictor of mortality when the score is 3 to 8 (7).

                       2.   A modified verbal and motor version has been developed to aid in the evaluation of consciousness level in infants and young children (Table 40.1).

TABLE 40.1  Glasgow coma scale for infants and children

     II.   Developmental considerations for specific organ systems

               A.   CNS injury

                       1.   Because their cranial bones are thinner and their head-to-body ratio is greater, the contents of a child’s cranial vault are more susceptible to injury, and that injury is much more likely to be global (characterized by diffuse cerebral swelling) rather than focal (8).

                       2.   In addition, elevated intracranial pressure occurs more often in children than adults and appears as severe diffuse brain edema.

                            a.   The goal of resuscitation must be to limit or prevent secondary brain injury by maximizing cerebral perfusion and oxygen delivery while minimizing increased intracranial pressure (ICP). (also see Chapter 12)

                            b.   Hypoxia and hypotension should be aggressively treated and ICP monitoring is recommended in infants and children with a GCS score of 8 or less.

                            c.   Epidural hematoma occurs in about 2% of pediatric head trauma admissions.

                            d.   In children with multiple injuries, 80% are diagnosed with head trauma, compared to 50% of adults.

                       3.   Currently favored therapeutic strategies for treatment of pediatric diffuse axonal injury (DAI) and vasogenic brain edema following head injury include an ICP less than 20 mm Hg, cerebral perfusion pressure (CPP) above 40 mm Hg, normovolemia, normotension, normoventilation, normo-chemistry, and anesthesia/sedation as needed (10).

                            a.   Specific current recommendations that have cycled through the years are outlined in Table 40.2.

               B.   Spinal cord injury

                       1.   Although spinal cord injury is relatively uncommon in children because of greater axial flexibility, cervical spine injury must nevertheless be presumed until ruled out.

                       2.   The most common cervical fracture usually involves the first two vertebrae.

                       3.   Even with child restraints in motor vehicles, an abrupt stop causes hyperflexion of the cervical spine and odontoid epiphysiolysis or vertebral fracture may result. The male:female ratio of spinal cord injury in children is 4:1.

                       4.   Other common spinal fractures in children are compression fractures and flexion-distraction (Chance) fractures of the lumbar spine, usually from inappropriate use of a lap seat belt (11).

                       5.   Spinal cord injury without radiologic abnormality (SCIWORA) syndrome is a problem unique to children (12).

                       6.   SCIWORA has been reported in 10% to 20% of children with spinal cord injury.

                            a.   The incompletely calcified vertebral column may transiently deform and allow cord or nerve root stretching with no residual anatomic evidence of injury.

                            b.   A documented neurologic deficit that may have changed or even resolved by the time the child has arrived in the emergency department may result in permanent disability if re-injury of the same area occurs.

                            c.   Thorough neurosurgical evaluation is essential whenever reliable evidence of even a transient neurologic deficit is present.

               C.   Neck injuries

                       1.   Cervical spine injury is rare in children, but there are some specific developmental features that are important considerations:

                            a.   Large head size relative to the neck and the rest of the body, increasing flexion, extension and shearing forces on the cervical spine

                            b.   Smaller paraspinous muscles to defend axial alignment against such forces

TABLE 40.2  Recommendations for traumatic brain injury

                            c.   Shallow and more horizontal facet joints

                            d.   Facet joint ligaments have increased elasticity

                            e.   Vertebral bodies are incompletely ossified

                            f.   Intervertebral disks have a higher water content and are more elastic, therefore increasing the vertical loading effect

                       2.   Furthermore, in younger children:

                            a.   Immature growth centers are more susceptible to sheering forces during rapid deceleration or hyperflexion-extension, particularly at the synchondrosis between the odontoid and vertebral body of C-2.

                            b.   There is a significant risk of SCIWORA (see above).

                       3.   The most common injuries in older children are vertebral body and arch fractures, usually in the lower cervical spine.

                       4.   Early airway control is crucial.

                       5.   Gross laryngotracheal injury, stridor, pulsatile bleeding, or expanding hematoma requires urgent airway examination under controlled conditions and operative treatment.

                       6.   Angiography, endoscopy, and bronchoscopy are useful for an advanced diagnostic examination beyond radiographic evaluation, which will also frequently involve the administration of an anesthetic to children.

               D.   Ocular trauma (13)

                       1.   Injuries to the eye and surrounding structures can be caused by blunt (ball, fist) or sharp (sticks) trauma as well as chemical trauma (caustic substances like cleaning material or pool supplies). Half of pediatric eye injuries occur during sporting events.

                       2.   Significant morbidity may result from pediatric eye trauma because of the continued development of the visual system up to 9 years of age; prognostic scoring systems specific to pediatric ocular injury have been reported (14).

                       3.   If a rupture of the globe is suspected, urgent ophthalmologic consultation will result in surgical exploration and repair.

                       4.   Orbital floor fractures may result in entrapment of extraocular muscles with complaints of diplopia.

               E.   Thoracic injuries

                       1.   Chest injury is the second leading cause of death in pediatric trauma.

                            a.   Thoracic injury occurs in about 5% to 12% of children hospitalized for trauma (15).

                            b.   Blunt trauma, particularly from MVAs, is responsible for most thoracic injuries (4,16).

                            c.   Because a child’s chest has greater cartilage content with incomplete rib ossification, isolated thoracic injuries commonly seen in adults are relatively uncommon in children (Table 40.3).

                            d.   However, because of the pliability of the pediatric rib cage and mediastinal mobility, significant intrathoracic injury may occur in the absence of external signs of trauma.

TABLE 40.3  Pediatric predisposing conditions to thoracic trauma morbidity

                       2.   Pulmonary contusion and pneumothorax are frequently present without rib fractures.

                            a.   Over half of rib fractures in children younger than 3 years of age may be due to child abuse.

                            b.   Helical chest CT scan can identify these injuries and may identify unsuspected injuries in up to 15% of children with normal chest X-ray film results. Physical examination is, unfortunately, notoriously unreliable.

                       3.   Extreme sporting injuries are an emerging area of concern in thoracic trauma in adolescents due to the high-energy impacts, lack of appropriate safety precautions, and remoteness from immediate medical attention. In one study, 6.1% of injured snowboarders sustained chest trauma, whereas only 2.7% of skiers had similar injuries (17).

                       4.   Following chest tube drainage, the chest should be explored urgently if 20% of the patient’s estimated blood volume is returned or for a continuous output of 2 mL/kg/hour, intercostal artery bleeding is commonly found.

                       5.   Approximately 90% of blunt pediatric thoracic injuries can be managed conservatively or with tube thoracostomy.

                            a.   Severe pulmonary injury may require mechanical ventilation.

                            b.   An epidural catheter may be useful to provide chest wall analgesia while avoiding excessive sedation.

                       6.   Pain control and aggressive pulmonary toilet are the principal treatment for rib fractures (18).

                       7.   Traumatic cardiac contusion may result in arrhythmia, myocardial hypokinesis, and abnormal cardiac serum enzymes.

                       8.   Traumatic diaphragmatic rupture occurs in about 1% of children with blunt chest trauma, with left-sided rupture being more common.

                            a.   Respiratory embarrassment from herniation of viscera into the thorax is commonly found.

                            b.   Early diagnosis usually results in repair via abdominal approach.

                       9.   Esophageal perforation from blunt trauma is rare in children. Primary repair is indicated if the perforation is diagnosed early.

                    10.   Traumatic asphyxia is the result of blunt, compressing thoracic trauma, with sudden airway obstruction and abrupt retrograde high pressure in the superior vena cava (4).

                            a.   It is a unique injury in pediatric trauma because of the increased compliance of the chest wall. Similar to an acute superior vena cava syndrome, patients with traumatic asphyxia have cervical and facial petechial hemorrhages or cyanosis associated with vascular engorgement and subconjunctival hemorrhage.

                            b.   CNS injuries, pulmonary contusions, and intra-abdominal injuries are common associated injuries.

               F.   Abdominal injuries

                       1.   A child’s small, pliable rib cage and undeveloped abdominal muscles provide little protection for major organs, and children are therefore more vulnerable to major abdominal injuries with very minor forces.

                       2.   Solid organs (spleen, liver, kidneys) are the most vulnerable to injury; however, the mortality of these injuries is 3% compared to 10% in adults.

                       3.   Abdominal wall bruising

                            a.   Bruising of the abdominal wall after motor-vehicle collision is an important finding (19).

                            b.   The sensitivity, specificity, positive predictive value, and negative predictive value for significant intra-abdominal injury are 73.5%, 98.8%, 11.5%, and 99.9%, respectively.

                            c.   Fluid in the abdomen on CT scan without associated solid organ injury should raise suspicion for bowel injury.

                            d.   In the setting of abdominal wall bruising and unexplained fluid in the abdomen, serial abdominal examinations and further investigations are indicated.

                       4.   Stomach injuries

                            a.   Most abdominal injuries in children are due to blunt trauma, and blunt injuries to the stomach occur more frequently in children than in adults.

                            b.   The injury is usually a blowout or perforation of the greater curvature (20).

                            c.   Children who are struck by a vehicle or who fall across bicycle handlebars shortly after eating a meal are at greater risk.

                            d.   Stomach injury should be strongly considered if the child has peritoneal signs and/or bloody nasogastric drainage.

                            e.   Abdominal X-ray films may show a pneumoperitoneum.

                       5.   Penetrating duodenal injuries

                            a.   These injuries are relatively uncommon in children compared to adults.

                            b.   Most pediatric duodenal injuries, such as intramural duodenal hematoma, are from blunt trauma and are often associated with child abuse.

                            c.   Other causes include falls or mishaps with bicycles or go-carts.

                       6.   Small-intestinal injury

                            a.   Hollow viscus injury is the most common intra-abdominal organ injury in restrained children involved in an MVA (20).

                                    (1)   Rapid deceleration may cause the lap belt to compress the intestines against the spine. An increase in intraluminal pressure may lead to rupture or tear.

                                    (2)   Duodenal hematoma with subsequent obstruction may result.

                                    (3)   Insidious from the onset, the obstruction may present several weeks after blunt intestinal injury as persistent nausea and bilious emesis.

                                    (4)   Mesenteric hematoma or tear is also possible.

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