Head

Head injuries are potentially more dangerous in children than in adults for several reasons. First, developing neural tissue is delicate and the softer bones of the pediatric skull allow impact forces to be transmitted directly to the underlying brain, especially at points of bony contact. Second, intracranial bleeding in infants in whom the fontanelles and sutures remain open may, on rare occasions, be severe enough to cause hypotensive shock. Third, the proportionately larger size of the head, when coupled with the injury mechanisms commonly observed in children, generally leads to head trauma with a loss of consciousness. As a consequence, the voluntary muscles of the neck lose their tone which can lead to soft tissue obstruction in the upper airway and hypoxia. Hypoxia exacerbates and potentiates the initial traumatic injury to the brain (secondary insults). See Chapter 17 for more information about head injuries.

Neck

Cervical spine injury is a relatively uncommon event in pediatric trauma. It affects approximately 1.5% of all seriously injured children, and occurs at a rate of 1.8/100,000 population, in contrast to closed-head injury, which occurs at a rate of 185/100,000 population.50–52 The pediatric surgeon should also be aware of normal variants of cervical spine anatomy. The greater elasticity of the interspinous ligaments and the more horizontal apposition of the cervical vertebrae also give rise to a normal anatomic variant known as pseudosubluxation, which affects up to 40% of children younger than age 7 years. The most common finding is a short (2–3 mm) anterior displacement of C2 on C3, although anterior displacement of C3 on C4 also may occur. This pseudosubluxation is accentuated when the pediatric patient is placed in a supine position, which forces the cervical spine of the young child into mild flexion because of the forward displacement of the head by the more prominent occiput. The greater elasticity of the interspinous ligaments also is responsible for the increased distance between the dens and the anterior arch of C1 that is found in up to 20% of children.

When an injury to the cervical spine does occur, it frequently occurs at C2, C1, and the occipitoatlantal junction. The injuries are above the nerve roots that give rise to diaphragmatic innervation (C4) and predispose the afflicted child to respiratory arrest as well as paralysis. The increased angular momentum produced by movement of the proportionately larger head, the greater elasticity of the interspinous ligaments, and the more horizontal apposition of the cervical vertebrae are responsible for this spectrum of injuries. Subluxation without dislocation may cause spinal cord injury without radiographic abnormalities (SCIWORA). SCIWORA accounts for up to 20% of pediatric spinal cord injuries as well as a number of prehospital deaths that were previously attributed to head trauma.53–55

Chest

Serious intrathoracic injuries occur in 6% of pediatric blunt trauma victims.⁵⁶ Although thoracostomy is required in about 50%, thoracotomy is seldom needed. Lung injuries, pneumothorax and hemothorax, and rib and sternal fractures occur most frequently (Table 14-3). Injuries to the heart, diaphragm, great vessels, bronchi, and esophagus occur less frequently, but have higher mortality rates associated with them. Because blunt trauma is nearly ten times more deadly when associated with major intrathoracic injury, thoracic injury serves as a marker of injury severity, even though it is the proximate cause of death in less than 1% of all pediatric blunt trauma.⁵⁷

The thorax of the child usually escapes major harm because the pliable nature of the cartilage and ribs allows the kinetic energy from forceful impacts to be absorbed without significant injury, either to the chest wall itself or to underlying structures. Pulmonary contusions are the typical result, but are seldom life-threatening. Pneumothorax and hemothorax, due to lacerations of the lung parenchyma and intercostal vessels, occur less frequently.

Abdomen

Serious intra-abdominal injuries occur in 8% of pediatric blunt trauma victims and are caused by crushing the solid upper abdominal viscera against the vertebral column, sudden compression and bursting of the hollow upper abdominal viscera against the vertebral column, or shearing of the posterior attachments, including the vascular supply, of the upper abdominal viscera after rapid deceleration (see Table 14-3).^56,58 Injuries to the liver (27%), spleen (27%), kidneys (25%), and gastrointestinal tract (21%) occur most frequently and account for most of the deaths from intra-abdominal injury. Injuries to the great vessels (5%), genitourinary tract (5%), pancreas (4%), and pelvis (<1%) occur less frequently and account for few of the deaths that result from intra-abdominal injury. Most solid visceral injuries are successfully managed nonoperatively, especially those involving the kidneys (98%), the spleen (95%), and the liver (90%).^59–61

The abdomen of the child is vulnerable to injury for several reasons. Flexible ribs cover only the uppermost portion of the abdomen. Thin layers of muscle, fat, and fascia provide little protection to the large solid viscera. Also, the pelvis is shallow, lifting the bladder into the abdomen. Moreover, the overall small size of the abdomen predisposes the child to multiple rather than single injuries as energy is dissipated from the impacting force. Finally, gastric dilatation due to air swallowing (which often confounds the abdominal examination by simulating peritonitis) leads to ventilatory and circulatory compromise by limiting the diaphragmatic motion, increasing the risk of pulmonary aspiration of gastric contents, and causing vagally mediated dampening of the normal tachycardic response to hypoxia caused by hypoventilation or hypovolemia.

Skeleton

Although they are the leading cause of disability, fractures are rarely an immediate cause of death from blunt trauma. They are reported to occur in 26% of serious blunt-injury cases and constitute the principal anatomic diagnosis in 22%.⁹ Upper extremity fractures outnumber lower extremity fractures by 7 : 1, although, in serious blunt trauma, this ratio is 2 : 3. The most common long bone fractures sustained during pedestrian/MVCs in children are fractures of the femur and tibia. Falls are typically associated with both upper and lower extremity fractures if the fall height is significant (from the window of a high-rise dwelling or the top of a bunk bed, but not from falls from standard beds or down stairs).^62–65 Because isolated long bone and stable pelvic fractures are infrequently associated with significant hemorrhage, a diligent search must be made for another source of bleeding if signs of shock are observed.^66,67 Unstable pelvic fractures are an uncommon feature of childhood injury, but unilateral (type III) or bilateral (type IV) anterior and posterior disruptions are those most often associated with major hemorrhage and must be recognized early and treated.⁶⁸

The pediatric skeleton is susceptible to fractures because cortical bone in childhood is highly porous whereas the periosteum is more resilient, elastic, and vascular. This results in higher percentages both of incomplete (torus and greenstick) fractures and complete, but nondisplaced fractures. Long-term growth disturbances also may complicate childhood fractures. Diaphyseal fractures of the long bones cause significant overgrowth whereas physeal (growth plate) fractures cause significant undergrowth. Both result in limb length discrepancies unless treated.

Primary Survey

Early management of childhood trauma begins in the field and continues in the emergency department.81,82 A primary survey of the airway, breathing, circulation (see Box 14-1) and neurologic disabilities (Box 14-2) should be completed to identify and correct deficits that pose an immediate threat to life. The primary survey continues with complete exposure of the patient to ensure that no injuries are missed, taking care to avoid hypothermia. The placement of therapeutic adjuncts, such as a urinary and gastric catheter (unless contraindicated), is also completed during this initial survey. Diagnostic adjuncts, such as pulse oximetry, radiographs, and focused assessment by sonography in trauma (FAST), facilitate the early recognition and treatment of immediate threats to vital functions (Box 14-3). The complete ‘trauma series’ of radiographs obtained as an adjunct to the primary survey in adults may not always be necessary in children, since the lateral cervical spine radiograph will not detect SCIWORA, and the screening pelvic radiograph seldom identifies a pelvic fracture. If a pelvic fracture is suspected on physical examination, a computed tomography (CT) scan should be obtained.^83,84

Resuscitation

Any child initially seen with major trauma should receive breathing support with high-concentration oxygen by the most appropriate means. For the child with respiratory distress (increased work of breathing), a nonrebreather mask normally will suffice, provided the airway is open and breathing is spontaneous. For the child with significant respiratory distress (labored or inadequate work of breathing), assisted ventilation via face-mask or an endotracheal tube (ETT) attached to a bag-valve device should be immediately available. Endotracheal intubation with rapid-sequence induction techniques is necessary in respiratory failure.

The first step in management of the circulation is control of bleeding. Direct pressure using sterile dressings is applied to all actively bleeding external wounds. Blind clamping is avoided, owing to the potential risk of injury to neurovascular bundles. Military experience suggests that commercial arterial tourniquets, and topical hemostatic agents such as chitosan granules or powder, zeolite granules, and kaolin clay, are effective in stopping major arterial hemorrhage, and massive arteriolar, venular, and capillary oozing from large open wounds. Recent data suggests equivalent effectiveness for tourniquets in children.⁸⁵ However, because no reports of topical hemostatic agent use in children have been published to date, no recommendation can be made regarding its applicability in civilian pediatric trauma.

The child with significant trauma will require volume resuscitation if signs of hypovolemic shock are present. Intraosseous access should be used if conventional intravenous access with peripheral large bore catheters is not rapidly obtainable. Central venous catheter insertion, except in cases when venous access cannot otherwise readily be obtained, is not warranted. Simple hypovolemia usually responds to 20–40 mL/kg of warmed lactated Ringer’s solution. However, frank hypotension (defined clinically by a systolic blood pressure less than 70 mmHg plus twice the age in years) typically requires 40–60 mL/kg of warmed lactated Ringer’s solution followed by 10–20 mL/kg of warmed packed red blood cells. To avoid the greater mortality associated with coagulopathy and shock on hospital admission, a 1 : 1 : 1 or 2 : 1 : 1 ratio with fresh frozen plasma and platelet concentrates should be instituted when massive uncontrolled hemorrhage is present and a massive transfusion protocol is invoked.86–88 Urinary output should be measured in all seriously injured children as an indication of tissue perfusion. The minimum urinary output that indicates adequate renal perfusion is 2 mL/kg/h in infants, 1 mL/kg/h in children, and 0.5 mL/kg/h in adolescents.

Due to the ability of a child’s blood vessels to compensate vigorously for hypovolemia by intense vasoconstriction, systolic hypotension is a late sign of shock and may not develop until 30–35% of circulating blood volume is lost.⁸⁹ Thus, any child who cannot be stabilized after infusion of 40–60 mL/kg of lactated Ringer’s solution and 10–20 mL/kg of packed red blood cells likely has internal bleeding and needs an operation. If a child initially is in shock, has no signs of intrathoracic, intra-abdominal, or intrapelvic bleeding, but fails to improve despite seemingly adequate volume resuscitation, other forms of shock (obstructive, cardiogenic, neurogenic) should be considered. Most children in hypotensive shock are victims of unrecognized hemorrhage that can be reversed only if promptly recognized and appropriately treated by means of rapid blood transfusion and immediate intervention, particularly if major intrathoracic or intra-abdominal vessels are injured.^90–93

Secondary Survey

Once the primary survey has been performed, and the resuscitation phase is ongoing, a secondary survey is undertaken. This consists of a ‘SAMPLE’ history (symptoms, allergies, medications, past illnesses, last meal, events, and environment) and a complete head-to-toe physical examination (including all body regions and organ systems). The physician’s chief responsibility is to identify life-threatening injuries that may have been overlooked during the primary survey, such as a tension pneumothorax. Physical findings will also assist in determining other injuries that are not readily apparent. For example, drainage from the nose or ears, or any evidence of midface instability, suggests a basilar skull fracture (which precludes passage of a nasogastric tube) or an oromaxillofacial fracture (which may threaten the airway). All skeletal components should be palpated for evidence of instability or discontinuity, especially bony prominences such as the anterior superior iliac crests, which commonly are injured in major blunt trauma. In the absence of obvious deformities, fractures should be suspected if bony point tenderness, hematoma, spasm of overlying muscles, an unstable pelvic girdle, or perineal swelling or discoloration is found.

Selective laboratory evaluation is an integral part of the secondary survey, although routine trauma laboratory panels are of limited utility owing to their relatively low sensitivity and specificity.94–96 Arterial blood gases are important in determining the adequacy of ventilation (PsCO₂), oxygenation (PsO₂), and perfusion (base deficit).^97,98 However, the critically important determinant of blood oxygen content is the blood hemoglobin concentration. Serial hemoglobin values better reflect the extent of blood loss than does the initial value. Elevations in serum levels of transaminases or amylase and lipase suggest injury to the liver or pancreas, but the infrequency of pancreatic injury makes the latter cost ineffective versus the former.^99,100 Urine that is grossly bloody or is positive for blood by dipstick or microscopy (>50 red blood cells per high-power field) suggests kidney trauma.¹⁰¹

Selective radiologic evaluation is another important part of the secondary survey. CT of the head (without contrast) and abdomen (intravenous and oral) should be obtained as indicated. However, CT should be employed only when the short-term benefit of accurate diagnosis is felt to outweigh the long-term risk of late malignancy, particularly for body regions such as the cervical spine and the thorax for which conventional imaging is adequate. When utilized, the CT should be performed using radiation doses ‘as low as reasonably achievable’ (ALARA), consistent with the ‘image gently^®’ protocols advocated by The Alliance for Radiation Safety in Pediatric Imaging.102–108

CT of the head should be performed whenever loss of consciousness has occurred, or if the GCS score is <15.¹⁰⁹ It can be safely avoided in children <2 years of age with: (1) normal mental status; (2) no scalp hematoma except frontal; (3) no loss of consciousness or loss of consciousness for less than five seconds; (4) nonsevere injury mechanism; (5) no palpable skull fracture; and (6) normal activity according to parents. Recommendations for not obtaining a head CT in children ≥2 years of age and older include: (1) normal mental status; (2) no loss of consciousness; (3) no vomiting; (4) nonsevere injury mechanism; (5) no signs of basilar skull fracture; and (6) no severe headache.¹¹⁰ CT of the chest adds little to what is already known from the chest radiograph obtained during the primary survey, since the incidental pulmonary contusions identified by CT of the chest do not correlate with increased fatality.^111,112 CT of the cervical spine may facilitate earlier identification of vertebral injury, but does so at the cost of increased radiation dose.¹¹³ CT of the abdomen should be obtained: (1) in intubated patients; (2) with signs of internal bleeding (abdominal tenderness, distention, bruising, or gross hematuria), a history of hypotensive shock (which has responded to volume resuscitation), or a hematocrit <30%; (3) if a femur fracture is evident; (4) if serum transaminase levels are elevated; (5) if significant microscopic hematuria is present, or (6) if the mechanism of injury is deemed significant.^114,115

Sonography serves an adjunctive role in the imaging of pediatric trauma. FAST itself is most useful in detecting intra-abdominal blood, but is not sufficiently reliable to exclude blunt abdominal injury, although it does have the advantage that such injuries can be detected by repeated examination.116–123 Therefore, like its historical predecessor diagnostic peritoneal lavage, FAST adds relatively little to the management of pediatric abdominal trauma, since unstable patients with presumed intra-abdominal injuries need immediate operation, while stable patients are managed nonoperatively without regard to the presence of intra-abdominal blood.^124–128 However, diagnostic sonography has been successfully used in screening for intra-abdominal injuries when abdominal CT is unavailable or contraindicated.¹²⁹

Physical Support

The care of children with major traumatic injury also involves assessment and treatment of somatic pain. Two pain scales have now been validated.¹³⁰ In patients who are not eating, nutritional support is recommended.¹³¹ In children who have sustained injuries resulting in hematomas, low-grade fever may develop as these are resorbed. However, high spiking fevers should prompt investigation for a source such as infected hematomas, effusions, or pelvic osteomyelitis. Children with chest tubes or long-term indwelling urinary catheters are at risk for systemic infection and should receive prophylactic or suppressive antibiotics as long as the tube or catheter is required.

Emotional Support

Efforts must be made to attend to the emotional needs of the child and family, especially for those families facing the death of a child or a sibling.¹³² In addition to the loss of control over their child’s destiny, parents of seriously injured children also may feel enormous guilt, whether or not these feelings are warranted. The pediatric surgeon should attempt to create as normal an environment as possible for the child and allow the parents to participate meaningfully in postinjury care, as acute stress disorder symptoms in children and parents are common after injury.¹³³ In so doing, treatment interventions will be facilitated as the child perceives that parents and staff are working together to ensure an optimal recovery, with the added benefit that long-term psychological effects such as posttraumatic stress disorder may be averted.¹³⁴ Even so, depression is increasingly recognized as a serious complication in adolescents after major trauma. Risk factors for depression include high injury severity, other family members injured, low socioeconomic status, and suicidal ideation or attempt prior to the current traumatic event.¹³⁵

Nonaccidental Trauma

Nonaccidental trauma (NAT) is the underlying cause of 3–5% of significant traumatic injuries in childhood, and is a major cause of morbidity and mortality among children referred to pediatric trauma centers.9,136 Although a detailed review of the mechanisms, patterns, presentations, and findings of NAT is beyond the scope of this chapter, NAT should be suspected when: (1) the injury remains unexplained; (2) a lengthy delay occurs in obtaining treatment; (3) the history is vague or otherwise incompatible with the observed physical findings; (4) the caretaker blames siblings or playmates or other third parties, or protects other adults rather than the child; (5) cutaneous bruises or skeletal fractures are found in multiple stages of healing or in unusual locations; (6) skeletal fractures are found in the diaphyses of long bones in infants or children too young to walk; (7) scald or contact burns are found in unusual locations or patterns; or (8) unconsciousness is said to have occurred in association with a low fall.^137,138 As with unintentional trauma, traumatic brain injury is the leading cause of death in NAT. The term ‘shaken baby syndrome’, characterized by the classic triad of altered mental status, bilateral subdural hematomas, and retinal hemorrhages, has largely been supplanted by the more inclusive term ‘abusive head trauma’.^139,140 Although the initial assessment and medical treatment of physical injuries is no different from that for any other mechanism of injury, the sociomedicolegal management of suspected cases of NAT requires a special approach. The crucial role played by the pediatric trauma service and the pediatric trauma registry in early recognition and adequate documentation of potentially abusive injuries is paramount.^141,142 Reports of suspected NAT must be filed with local child protective services in every North American state, province, and territory, as well as in most developed nations worldwide. Still, it must be emphasized that confrontation and accusation hinder treatment and rehabilitation, and have no place in the management of the potentially abused child, regardless of the nature of the injury, or the identity of the perpetrators.

Penetrating Injuries

All penetrating wounds are contaminated and must be treated as infected. Accessible missile fragments should be removed (once swelling has subsided) to prevent the development of lead poisoning (especially those in contact with bone or joint fluid).¹⁴³ Thoracotomy is usually not required except for massive hemothorax (20 mL/kg) or ongoing hemorrhage (2–4 mL/kg/h) from the chest tube, persistent massive air leak, or food or salivary drainage from the chest tube. Laparotomy is nearly always required for gunshot wounds as well as stab wounds associated with hemorrhagic shock, peritonitis, or evisceration, although nonoperative management may be employed in carefully selected cases.¹⁴⁴ Thoracoabdominal injury should be suspected whenever the torso is penetrated between the nipple line and the costal margin. A diaphragmatic injury should be suspected if peritoneal irritation develops after thoracic penetration, food or chyle is recovered from the chest tube, or if injury-trajectory or imaging studies suggest the possibility of diaphragmatic penetration. Tube thoracostomy, followed by laparotomy for repair of the diaphragm and/or damaged organs, is mandated with such signs, although laparoscopy is being used with increasing frequency.^145–148

Systems Issues

Pediatric patients, at significant risk for death from multiple and severe injuries, are best served by a fully inclusive trauma system that incorporates all appropriate health care facilities and personnel to the level of their resources and capabilities.149,150 Unfortunately, access to specialty pediatric trauma care, including pediatric intensive care, remains highly variable.^151,152 Moreover, collaboration with local public health agencies (in programs for injury prevention and control), as well as local public health, public safety, and emergency-management agencies (in regional disaster-planning efforts) is necessary.^149,150 Although the regional trauma center is at the hub of the system, area trauma centers may be needed in localities distant from the regional trauma center. All trauma centers, whether adult or pediatric, must be capable of the initial management of the injured child or infant. This requires the immediate availability of a resuscitation team trained and credentialed for the management of pediatric trauma, for which structured review and simulation training have been shown to improve team performance, while family presence during resuscitation rarely hinders it.^153–158 All other hospitals in the region should participate as they are able, and must be fully capable of initial resuscitation, stabilization, and transfer of pediatric trauma patients. Finally, a regional trauma advisory committee should include pediatric representation that has the authority to develop and implement guidelines for triage of pediatric trauma within the system to verified pediatric-capable trauma centers.^159,160 Mature systems should expect that seriously injured pediatric patients will be primarily transported to pediatric trauma centers.¹⁶¹

Transport Issues

Pediatric victims of multisystem trauma should undergo direct primary transport from the injury scene to a pediatric-capable trauma center.28–47,82,150 If this is not possible, additional secondary transport from the initial receiving hospital to the pediatric trauma center is needed. Transport providers must be capable of critical pediatric assessment and monitoring, and skilled in the techniques of endotracheal intubation and vascular access, as well as drug and fluid administration in children.^162,163 Specialized pediatric transport teams, staffed by physicians and nurses with advanced training in pediatric trauma and critical care treatment and transport, should be used whenever possible, as complications related to endotracheal intubation and vascular access are the leading causes of adverse events during transport, which occur twice as often as in the PICU and ten times more often without a specialized team.^164,165

Hospital Preparedness

Regional pediatric trauma centers should be located in trauma hospitals with comprehensive pediatric services (a full-service general, university, or children’s hospital) that demonstrate an institutional commitment to pediatric trauma care, including child abuse.28–47,150 Adult trauma centers can achieve results comparable to those of pediatric trauma centers if pediatric subspecialty and nursing support (pediatric emergency, acute care, and critical care medicine) are available.^38–47,150 Finally, an organized pediatric trauma service must be available within the regional pediatric trauma center that, in addition to exemplary patient care, provides education and research in pediatric trauma, and leadership in pediatric trauma system coordination.

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