Airway

Initial evaluation of the airway is of utmost importance. A child who can phonate normally has a patent airway. In an unconscious patient, inspection for foreign body in the pharynx and for midface or mandibular injuries, which could compromise airway patency, should occur, as well as observation of obvious stridor or stertor with respiratory effort. Hoarseness or crepitus over the tracheal cartilage should raise concern for laryngeal fracture. After these areas have been examined, the physician should quickly move to secure an airway if necessary or move on to the assessment of ventilatory efficacy.

Readers are directed to Chapter 1 for complete information about airway evaluation and management. However, it is important to reiterate here the need for inline stabilization of the cervical spine (c-spine) during this assessment and treatment, especially if intubation is attempted. The collar should be opened or removed before direct laryngoscopy because it can impede successful visualization of the larynx. An assistant should hold the patient in the midclavicular line with the ears firmly between the lower arms to eliminate movement of the c-spine during intubation.

Breathing

Evaluation of effective ventilatory effort occurs after the airway evaluation. The chest wall excursion should be observed for symmetric chest rise. Visual inspection, including of the axillae and back, should identify open wounds. The clinicians should evaluate for symmetry and adequacy of breath sounds by auscultating the chest. Asymmetric chest rise or asymmetric breath sounds suggest the possibility of pneumothorax, hemothorax, flail chest, or an open chest wound.

Asymmetry in breath sounds may signify pneumothorax or hemothorax. This is important to note on the initial examination even when it appears clinically insignificant because a simple pneumothorax can be quickly converted to a tension pneumothorax when a patient is ventilated with positive pressure by bag–valve–mask (BVM) or endotracheal ventilation. Also, children are especially sensitive to the development of tension pneumothorax because of their relatively compliant and mobile mediastinum. Radiographs can be used to determine the presence and amount of air or blood in the pleural space. In a more clinically stable patient, a small simple pneumothorax may be treated noninvasively with inpatient monitoring, oxygen therapy, and serial chest radiography. Larger pneumothoraces or hemothoraces should be managed with chest tube drainage.

An absence of breath sounds, especially in conjunction with hypotension, should alert the clinician to possible tension pneumothorax. Tracheal deviation to the opposite side and hyperresonance of the chest to percussion may be less obvious in pediatric patients, and the more mobile mediastinum in this age group may produce vascular collapse in a more rapid fashion. Needle decompression can be immediately undertaken in such circumstances, with the introduction of a large-bore over-the-needle catheter (e.g., a 14-gauge intravenous [IV] catheter) into the second intercostal space in the midclavicular line. Needle decompression necessitates the subsequent placement of a chest tube. Massive hemothorax can present in a similar fashion, although the chest should be dull to percussion, and severe hypotension often predominates because of the significant blood loss (Figure 8-1).

Figure 8-1 Tension pneumothorax.

Open chest wounds create loss of the usual negative pressure upon inspiration that is needed to inflate the lung. If the chest wall defect is large compared with the airway, air will preferentially be brought into the defect as opposed to the airway, significantly impairing effective ventilation. An occlusive dressing should be placed over sucking chest wounds, closed on three sides, to allow for air to escape during exhalation but preventing air from entering during inspiration.

Circulation

After the respiratory assessment, hemodynamic status should be evaluated by auscultation of heart sounds; palpation of central pulses (femoral or brachial), paying attention to both the rate and quality; and rapid evaluation of skin color, capillary refill, and level of consciousness. Any obvious area of external hemorrhage should be identified and addressed with pressure dressings; whip stitching; or in the case of massive scalp wounds, stapling to control bleeding.

Complete details on hypoperfusion and shock may be found in Chapter 2. In patients who have sustained significant traumatic injuries, IV access should be secured as quickly as possible with two large-bore IV catheters placed in large peripheral veins. If peripheral access attempts are unsuccessful in a patient showing signs of shock, clinicians should proceed quickly to obtain interosseous (IO) access. IO lines should not be placed distal to any obvious fractures.

Shock in a trauma patient should be presumed to be attributable to hypovolemia secondary to hemorrhage. Because most pediatric trauma victims have sustained blunt trauma, hemorrhage may be attributable to internal injuries such as splenic or hepatic lacerations and not readily visualized. However, other causes of traumatic shock must be considered, especially in patients with shock unresponsive to fluid resuscitation or with hemodynamic collapse. Chief among these causes are tension pneumothorax, tension hemothorax, and cardiac tamponade.

Cardiac tamponade is more common with penetrating chest wounds but can be caused by rupture of the myocardium with blunt traumatic force. As with tension pneumothorax, patients with cardiac tamponade present with tachycardia, hypotension, and distended jugular veins. However, with tamponade, there is no tracheal deviation. Pulsus paradoxus, which is exaggeration of the normal decrease in blood pressure with spontaneous inspiration, may be present in association with tamponade. Rapid bedside ultrasonography can help make the diagnosis, but if unavailable or if the patient is hemodynamically unstable, pericardiocentesis can be used to diagnose and treat tamponade (Figure 8-2).

Figure 8-2 Cardiac tamponade and pericardiocentesis.

Finally, hypotension in the pediatric trauma patient can, rarely, be caused by spinal cord injury. This should be suspected in a patient with an appropriate injury mechanism who is observed to have bradycardia, or a lack of appropriate tachycardia, in the face of hypotension.

The rapid installation of IV fluids is standard first-line therapy for shock. Boluses of 20 mL/kg of 0.9% saline solution or lactated Ringer’s solution should be given rapidly. If there is no response after 40 mL/kg is administered, then blood products should be given. In a child with decompensated shock caused by trauma, O-negative packed red blood cells (PRBCs) should be pushed rapidly until type-specific or crossmatched blood is available. In patients who require massive transfusion, fresh whole blood or fresh-frozen plasma and platelets in addition to PRBCs should be considered. If shock is not rapidly reversed with transfusion therapy, identification of the source of hemorrhage must be achieved, and operative management to halt the hemorrhage must be immediately undertaken.

Disability

After the patient’s hemodynamic status has been stabilized, the neurologic status is evaluated. The symmetry, size, and briskness of pupillary response should be documented along with the level of responsiveness. Numerical scales, such as the Glasgow Coma Scale (GCS, see Figure 1-8), are used to generate structured assessments of the level of responsiveness. This allows for comparisons in mental status evaluations over time, comparisons of assessments performed by different clinicians, and improved communication among providers. The GCS has been adapted for use in preverbal patients as well. A more straightforward, although somewhat less nuanced, system for rapid neurologic evaluation is the AVPU (awake, verbal, pain, unresponsive) system. Abnormalities in the pupillary response or level of consciousness should increase concern for intracranial injuries and alert the team to prepare for possible interventions such as intubation for airway protection or to improve ventilation, mannitol, or hypertonic saline administration for increased intracranial pressure (ICP) or emergent neurosurgical intervention.

In patients who are alert and can cooperate with the examination, the patient’s strength and sensation should be assessed in all four extremities. Tenderness and deformities of the cervical, thoracic, and lumbar spine should also be assessed. In preverbal children, this assessment can be challenging. Observation of spontaneous movement, watching how the patient reaches for objects, and the patient’s response to touch or painful stimulus should be assessed. The spine should be palpated, but it is difficult to ascertain tenderness in these children.

Exposure and Environment

The final step in the primary survey is to ensure that all clothing has been removed from the patient so that all areas of the body can be visually inspected for injury. In this step, the patient’s core temperature should be evaluated with the understanding that trauma patients are often cold because of the environment and significant blood loss. Rewarming should be undertaken, as well as the prevention of heat loss now that the patient is fully exposed. Children, especially, lose a significant amount of heat through their skin because of their relatively large body surface area. The ambient temperature of the resuscitation area should be kept warm, and when inspection for injury is completed, warm blankets should be used to cover the patient to prevent heat loss.

Some sources have suggested adding “Family” as the final part of the primary survey in the care of injured children to prompt providers to remember to inform family members quickly about the child’s status and injuries as well as to consider allowing family members to be present for the resuscitation. Family presence at resuscitation has not been shown to hinder care and has been shown to increase family satisfaction. When family members are present for resuscitation efforts, a trained health care associate (nurse, social worker, or chaplain) must be assigned to be with and communicate to the family members to help them understand the efforts that are being undertaken.

Head

The initial evaluation of the head involves inspection for evidence of injury to the skull, as well as assessment of level of consciousness and neurologic status, which may indicate underlying brain injuries. Locations of all hematomas, lacerations, abrasions, depressions, and areas of tenderness should be documented. Because the middle meningeal artery runs through the temporal bone, hematomas or other signs of injury in the temporal region raise concerns for the possibility of an underlying epidural hematoma as a result of tearing of this artery. Epidural hematomas (Figure 8-3) are often described as presenting with a lucid interval followed by a rapid deterioration in mental status when the volume of blood filling the epidural space reaches the threshold to cause significant mass effect. On computed tomography (CT), epidural hematomas are seen as a convex fluid collection between the skull and brain. Significant epidural hematomas represent a neurosurgical emergency because evacuation of the growing hematoma before herniation can be lifesaving.

Figure 8-3 Epidural hematoma.

Subdural hematomas are a second, more common intracranial hemorrhage. They may be seen without significant external signs of trauma. Subdural hematomas (Figure 8-4) are usually caused by tearing of small bridging veins from the surface of the cortex to the inner layer of the dura mater. These injuries are often caused by high-force, rapid flexion and extension of the head. CT will show concave fluid collections between the skull and brain. Although subdural hematomas are less likely to lead to the rapid onset of significant symptoms than are epidural hematomas, they are more often associated with significant underlying brain damage because of the mechanism of injury. In infants and toddlers, it is important to remember that subdural hematomas can be associated with nonaccidental injury from shaking the child or as part of the shake and impact syndrome (see Chapter 12).

Figure 8-4 Subdural hematoma.

Both epidural hematomas and subdural hematomas can become large enough to lead to significant increases in ICP (see Chapter 10). When ICP increases, herniation of brain tissue across the tentorium or downward through the foramen magnum may occur. Bradycardia, hypertension, and irregular respirations (Cushing’s triad) indicate impeding herniation. Transtentorial herniation is heralded by a decreased level of consciousness and asymmetric pupillary responses. Rapid therapy, including brief periods of hyperventilation and IV administration of 0.25 to 1.0 g/kg of mannitol or 5 mL/kg of 3% sodium chloride solution may temporize the situation until more definitive therapy, such as surgical evacuation of a hematoma or drainage of cerebrospinal fluid (CSF) through an intraventricular catheter, can occur.

Most children with significant head injuries caused by blunt trauma do not have surgically correctable lesions (e.g., epidural or subdural hematomas). Instead, diffuse axonal injury, which is characterized by diffuse edema and small, punctate hemorrhages on CT, is more common. All children with a decreased level of consciousness or other neurologic abnormalities after head injury should undergo CT to define their injuries and help to plan their immediate and subsequent care.

The care of children and adolescents with severe head injuries requires meticulous attention to the ABCs. Hypoxia, hypercarbia, and poor perfusion (shock) can all lead to secondary injuries in children who have sustained significant neurologic injury. In the face of increased ICP, cerebral perfusion pressure (CPP = Mean arterial pressure – Intracranial pressure) will be further compromised in patients who are allowed to remain in shock.

If mean arterial pressure (MAP) decreases, perfusion to areas of injury decreases, and injuries may be worsened. Therefore, attempts to manage ICP may be counterproductive unless CPP is preserved through the maintenance of MAP with appropriate volume resuscitation.

Most children who sustain head injuries have seemingly mild injuries and look well on initial presentation. In these children, the relatively low risk of underlying significant intracranial injuries must be weighed against the radiation involved in imaging the brain and the possible risk of malignancies in the future associated with this imaging. A decision rule based on a large, multicenter, prospective study has identified historical and physical findings associated with intracranial injuries on CT scans in children (Box 8-1). CT scans are rarely indicated in the absence of any of these findings in children.

Linear, nondisplaced skull fractures are the most common type of skull fracture in children, rarely require intervention, and are associated with a relatively good prognosis. Skull fractures that are diastatic or which extend into preexisting suture lines are more likely to require correction to prevent future development of leptomeningeal cysts at these sites. Skull fractures with significant depression causing risk to underlying brain tissue may also require surgical correction.

Basilar skull fractures require special evaluation and treatment because they raise concern for other injuries associated with the significant forces needed to produce them, as well as their unique location, which may lead to significant complications, including late intracranial hemorrhages, carotid artery dissections, and intracranial infections. Basilar skull fractures should be suspected when any of the following are present: “raccoon eyes” caused by periorbital ecchymoses; Battle sign or postauricular ecchymoses; hemotympanum; clear rhinorrhea or clear otorrhea caused by CSF leakage from the nose or ear, respectively; or cranial nerve VII or VIII dysfunction (Figure 8-5). Neurosurgical input should be obtained early in management.

Figure 8-5 Basilar skull fracture: physical findings.

Children with concussion after head trauma can have significant symptoms and prolonged recovery despite normal head imaging. Concussion—or more accurately, mild traumatic brain injury—is defined as a brief alteration in brain function with or without loss of consciousness caused by a blow or jolt to the head. Children and adolescents with concussions may have significant and long-lasting symptomatology, including headaches, dizziness, amnesia, confusion, difficulty concentrating, nausea, and vomiting. Older grading systems based on the initial signs and symptoms of injury are not predictive of subsequent outcomes and are no longer used by most experts.

The International Conference on Concussion in Sport has suggested that measures of recovery must be included in the determination of injury severity as well as in determining when someone who has sustained a concussion is ready to resume activities such as work and school attendance and return to sports participation. To limit the duration of symptoms in children after concussions, rest (including the concept of cognitive rest) should be encouraged and strict return-to-activity guidelines should be followed. This involves a gradual increase in both physical and mental activities.

Facial and eye injuries should be considered in all children with head injury. A thorough examination, including assessment of the stability of the facial bones and oral structures and a thorough examination of the eye and extraocular movements, must be completed. Injuries to the facial bones, including the maxilla and mandible, may lead to airway compromise, secondary infections, and cosmetic deformities if not recognized promptly and treated appropriately.

In alert patients, examination of the eye must include the assessment of the patient’s visual acuity and inspection of the globe, including the cornea, anterior chamber, and fundus, for signs of injury. Any concern for penetrating trauma to the globe or a hyphema or other serious injuries necessitates emergent evaluation by an ophthalmologist. In children in whom the extraocular movements are decreased, facial CT scans should be performed to assess for orbital fractures and possible entrapment of the extraocular muscles or other processes affecting the ophthalmic nerve.

Neck and Spine

Any child who has sustained a severe head injury should be assumed to have a c-spine injury and remain in spinal immobilization until there is clear clinical or radiologic evidence that there is no spinal injury. Plain radiographs and CT scans may aid in this evaluation, but in patients with a decreased level of consciousness, magnetic resonance imaging may be required. As long as immobilization is maintained, this can be delayed until the child has been stabilized and other major traumatic injuries have been addressed. In awake patients, clinical signs of spine injuries include posterior midline tenderness and limitation of motion. Even in patients with a normal level of consciousness, clinical clearance of the c-spine is especially difficult in patients who are preverbal and young children who are uncooperative because of fear, anxiety, or pain associated with other injuries. It is important to remember that children are at risk of spinal cord injury without radiologic abnormalities (SCIWORA) because of the relative ligamentous laxity found in their c-spines. Therefore, normal radiographs may not completely rule out injury to the spinal cord itself, and MRI may be necessary for complete diagnosis. Detailed discussion of spinal injuries can be found in Chapter 24.

Evaluation of the anterior neck should involve palpation to ensure that the trachea is in a midline position. Deviation should raise concern for tension pneumothorax or hemothorax. Blunt trauma to the anterior neck, hyperextension of the neck, or blunt trauma to the chest with forced exhalation against a possible closed glottis may cause laryngeal injury. Signs of laryngeal injury include a change in voice, dysphagia, odynophagia, hemoptysis, stridor, crepitus along the anterior neck, and obscuration of the cartilaginous landmarks.

In a patient with suspected laryngeal injury who requires intubation, consideration must be given to the possible complication of converting a partial tracheal laceration to a complete transaction or the creation of a false track when performing direct laryngoscopic intubation. As with prolonged BVM ventilation, laryngeal mask airways can also carry the risk of expanding subcutaneous and mediastinal free air. Preparation for possible surgical airway placement and the use of flexible fiberoptics for intubation may decrease these risks.

Evaluation of the neck should also involve inspection for signs of penetrating injury. The neck is often divided into three zones (Figure 8-6) according to the collection of structures at risk of injury, with zone I covering the area between the thoracic inlet and the cricoid cartilage, zone II covering the cricoid cartilage to the angle of the mandible, and zone III above the angle of the mandible. Injuries to zones I and II may be associated with pneumothorax or hemothorax. Injuries in zone II are the easiest to explore surgically but also the most likely to involve major vascular structures and therefore are often brought directly to the operating room for exploration if they extend through the platysma. If clinically stable, zone I and III injuries are often evaluated with diagnostic imaging to determine appropriate management before surgical exploration.

Figure 8-6 Zones of the neck.

Finally, although not always apparent in the initial evaluation, clinicians must have a high index of suspicion for injuries to the carotid artery, including carotid artery dissection, pseudoaneurysm, and thrombosis. Symptom onset, including stroke, may be delayed from the time of trauma. Ultrasonography, CT angiography, magnetic resonance angiography, and conventional angiography have all been used for diagnosis.

Chest

The evaluation of the chest should involve the familiar initial steps of inspection for external signs of trauma; palpation for deformities, crepitus, and tenderness; and auscultation of breath sounds. Children may sustain significant lung injury, including pulmonary contusions and pneumothorax (see above) without rib fractures because of their compliant rib cages. Therefore, external signs of trauma may be limited despite significant internal injuries.

Injuries to the chest wall, including the ribs, may occur. Flail chest should be suspected in any child with asymmetric chest rise, significant tenderness and crepitus on palpation of the ribs, and a high-velocity mechanism. Flail chest occurs when a segment of the chest wall becomes discontinuous with the rest of the thorax, usually requiring two or more ribs to be broken in two or more places to create this “floating” chest segment. Splinting because of pain from this injury can cause significant impairment of appropriate respiration, and the injury to the underlying lung tissue can further impair oxygenation and ventilation. Pain control and close monitoring for respiratory decompensation are required.

Simple rib fractures create significant pain and require appropriate analgesia but should heal completely without other intervention. However, splinting from inadequately controlled pain may lead to atelectasis and worsen any coexisting pulmonary issues. Fractures of ribs 1 to 3 require significant force and should alert the clinician to be aware of the possibility of other high-impact injuries.

Injuries to the chest may also involve mediastinal structures. Blunt cardiac injury may result in myocardial contusion, myocardial rupture, or chordae rupture with valvular insufficiency. Patients with myocardial rupture should present with cardiac tamponade. Patients with myocardial contusion will likely present with chest pain and tachycardia. Cardiac arrhythmias, evaluated with a 12-lead electrocardiogram, may also occur.

Although rare, aortic disruption may occur in blunt injuries, especially those associated with a rapid deceleration. Patients with aortic injuries who survive to the hospital tend to have incomplete lacerations, often located near the ligamentum arteriosum. Although initially hemodynamically stable, these incomplete lacerations carry a high risk of further acute deterioration if there is rupture of the contained hematoma. Such injuries should be considered when an appropriate mechanism exists; widened mediastinum, obliteration of the aortic knob, or deviation of the trachea or deviation of the nasogastric tube to the right (without other cause) may be present on plain radiographs of the chest. The presence of an apical cap, fractures of the first or second rib, and left-sided hemothorax are also concerning for aortic injuries. Transesophageal echocardiography and CT angiography are commonly used for diagnosis.

Esophageal injury is rare, with injury from penetrating trauma being more common than with blunt mechanisms. The presence of subcutaneous air or mediastinal air on a chest radiograph should increase suspicion for an esophageal injury, and its presence should be confirmed with contrast esophagography.

Finally, consideration should be given to the possibility of diaphragmatic rupture, especially in patients with sudden compressive forces to the abdomen such as may be seen with a lap belt in a motor vehicle collision. Protrusion of abdominal contents into the chest may lead to progressive respiratory distress. However, many traumatic diaphragmatic hernias remain asymptomatic, and diagnosis can be difficult. Placement of a nasogastric tube can assist with diagnosis before imaging. Chest radiographs and chest CT scans can be used for diagnosis, but sensitivity is not perfect. Therefore, diagnosis often occurs at a time remote from the injury. Indications on chest radiographs that should increase suspicion include elevation or blurring of the hemidiaphragm, a gastric tube in the chest, and obscuration of the hemidiaphragm by an abnormal gas shadow.

Abdomen

Abdominal injury is relatively common in children as a result of the large size of their abdomens relative to the rest of their bodies. In addition, their abdominal organs are less protected by their rib cages and abdominal musculature. The abdomen should be examined for tenderness, rigidity, and distension. CT scan is the initial imaging modality of choice in evaluating abdominal injuries in children. The sensitivity of focused assessment sonography in trauma (FAST) examination is operator dependent. To date, there have been mixed results in studies of efficacy in pediatric trauma victims; therefore, FAST is not routinely recommended for children. Direct peritoneal lavage is rarely used in the pediatric population.

The spleen is the most commonly injured abdominal organ (Figure 8-7). Patients with splenic lacerations may present with left upper quadrant pain that radiates to the left shoulder with or without signs of peritoneal irritation. The liver is also commonly injured in children sustaining trauma (Figure 8-8). Liver lacerations may present with right upper quadrant tenderness that may radiate to the right shoulder after blunt trauma. Hemodynamically stable children with spleen or liver lacerations can be conservatively managed with bed rest and close monitoring of vital signs and hematocrit levels. Children with unstable vital signs that do not improve with aggressive volume resuscitation may require operative intervention or embolization of bleeding vessels by an interventional radiologist experienced in the treatment of children with significant injuries. Children who have sustained significant splenic injuries, especially those who undergo splenectomy, are at increased risk of overwhelming sepsis with encapsulated bacteria (e.g., Streptococcus pneumoniae). Pneumococcal vaccination and consideration of long-term antibiotic prophylaxis (e.g., daily oral penicillin) should be considered based on the child’s age and clinical situation.

Figure 8-7 Splenic laceration.

Figure 8-8 Liver trauma.

Although the kidneys are more protected than other abdominal organs, renal injury should be suspected in children with injury to the flank or back, significant back pain, or gross hematuria (Figure 8-9). Urinalysis can be used as screening for more subtle injury, and CT or renal ultrasonography can be used to confirm and detail injuries.

Figure 8-9 Renal trauma.

Injury to the bowel is difficult to diagnosis, requiring a high degree of suspicion. Possible injuries to the intestines include perforation, hematomas, and mesenteric injuries. The initial CT scan may show pneumoperitoneum or extravasation of contrast, but often it is normal or shows nondescript bowel wall edema. Persistent abdominal pain, tenderness, or vomiting may be the only symptoms. Injuries to the abdomen by handlebars have been shown to lead to a significant risk of bowel and pancreas injury. Also, motor vehicle collisions during which children are restrained with inappropriately positioned seatbelts riding above the pelvis can lead to the significant abdominal injury triad of the “seatbelt sign” (abdominal wall contusion caused by the seatbelt), bowel injury, and Chance fracture (compression or flexion-distraction fracture of the lumbar spine). Bowel injuries often require surgical intervention to fully evaluate the extent of the injury and to allow for repair. Late diagnosis of bowel injuries may be associated with the development of peritonitis.

Pelvis

The pelvis should be evaluated for tenderness to palpation and stability. Determination that the pelvis is unstable on clinical examination correlates with open-book fractures of the pelvis. These injuries should be treated with placement of a pelvic splint to decrease the volume of the pelvis and the likelihood of severe hemorrhage. Lateral compression pelvic fractures, in contrast, are less often associated with significant blood loss and more frequently associated with injury to the bladder and urethra. Importantly, pelvic fractures are associated with other high-impact abdominal and retroperitoneal injuries that should be considered in the full evaluation of such patients.

Extremities and Neurologic Status

The final steps in the secondary survey include a rapid but complete evaluation of the extremities and evaluation for focal neurologic deficits. This is usually accomplished by palpation of the full extent of each extremity noting tenderness, lacerations, and deformity. Tenderness to palpation or observed deformity should prompt radiologic evaluation. Further discussion of common pediatric fractures can be found in Chapter 22. Neurologic evaluation is often accomplished in conjunction with the extremity evaluation, briefly testing strength and sensation of each extremity, with cooperation acting as a quick evaluation of mental status. Focal deficits raise concern for intracranial or spinal cord injury depending on the location and extent. Appropriate imaging of the head and spine should follow from the clinical examination, as appropriate.

Radiation

Many of the injuries discussed are definitively diagnosed using radiographs or CT scans. These imaging modalities are often necessary for the appropriate treatment of injured children. However, the use of ionizing radiation must be balanced with the risk of possible long-term iatrogenic injury caused by radiation exposure. Children, especially infants and toddlers, are particularly at risk for the development of secondary cancers caused by radiation because of the increased years of life after radiation and the increased susceptibility to the carcinogenicity of ionizing radiation. Therefore, ionizing radiation for diagnosis should be limited to instances in which there is either a significant clinical suspicion or the possibility of high-morbidity injuries. When imaging is necessary, pediatric radiation dose protocols that abide by the ALARA (as low as reasonably achievable) principles should be used.