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

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.

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).

Diagnostic Testing

      Key Points

Scope and Outline

Head injury is the leading cause of death and is responsible for 80% of pediatric trauma deaths. Annually in the United States, 500,000 emergency department (ED) visits and almost 100,000 hospital admissions are due to pediatric head trauma. The leading causes of head trauma are falls, motor vehicle collisions, bicycle accidents, auto-pedestrian accidents, diving injuries, sporting accidents, and child abuse.

Pathophysiology

Children have relatively larger heads than adults do. A child’s skull is thinner and less rigid than an adult’s, and infants and younger children have open or soft sutures, which can help decompress elevations in intracranial pressure. As a result, parenchymal injury may occur in the absence of a skull fracture.

Clinical Presentation

Major intracranial injuries may be immediately apparent from the patient’s depressed level of consciousness or confusion or from abnormal neurologic findings. Significant injuries may be present in a patient with completely normal neurologic findings. Early recognition and treatment of mild or moderately severe head injury in a child are as important as recognition and treatment of serious injuries (see Red Flags: Warning Signs box). An epidural hematoma in a mildly confused victim of a car accident can have dire consequences. It is important to screen for injuries to other systems and to aggressively treat a child with a head injury. Strict attention should be paid to maintaining oxygenation and cerebral perfusion in a head-injured child to avoid secondary injury.

Approach and Management

A physical examination should be performed with attention to any neurologic findings. Obvious external head and neck trauma may be an indicator of serious injury, although severe internal injury often exists with minimal or no external signs. The GCS or AVPU scale may be used to assess mental status. An age-appropriate neurologic examination may reveal deficits requiring further testing and treatment. The clinician should have a low threshold for managing the airway of a pediatric trauma patient with altered mentation.

Diagnostic Testing

The goal of diagnostic testing in children in whom intracranial injury is suspected is to identify those with injuries that will require intervention before the condition worsens. A secondary goal is to avoid unnecessary testing and admission, both to prevent overutilization of resources and to avoid unnecessary exposure to radiation. The most commonly used and most widely available options for the evaluation of children with head injuries are plain radiography of the skull, CT of the head, and observation with serial examinations.

Scope and Outline

Spinal cord injuries are uncommon in children and account for less than 2% of injuries found in pediatric trauma patients. Motor vehicle collisions represent the most common mechanism for this injury, and death is usually secondary to brain injury.

Pathophysiology and Anatomy